Braun Home Application/ Background check form

1. ffiS,Servicesandemp1oymentisavai1ab1etoa11PerSonS.ThoseappIicantsrequiringreasonable
accommodation to the application and/or irrt..ui.* pr"..., ,rr""16 ,rotis, a representalive of the Human Resources Department'
Applicant ID #
Name First
Address
I wutt -i
T
tr
n
T
City
Street /
Telephone # l. / Cellular/OtherPhone#( ) E-mailAddress
check the appropriate category and list the source')
I school
E lob rui.
E Staffing AgencY
I Government
Date of aPPlication
EmploYment AgencY
E oth..
Will you work overtime if required? ""'
Position(s) aPPlied for
Referral Source (Ptease
Employee
Advertisement
Company's Website
Other Internet
A14
PM f Yes trNo
Ifnecessary, best time to call you is ."""""""""'
E Ho*. I Cellular/Other Ifno, please exPlain
EY.s Exo May we contact You at work?
If yes, work number and best time to cail:
Ifyou are under 18 and it is required,
can you furnish a work permit?""""""
PT4 Are you able to perform the "essential functions" ofthe job
fo, *f,i.h you ui. applpng (with or without reasonable
accommodation)?
lhisquestio:l'lsnotdesignedls*iicitinfc'rrnationai:*niallepFli{$nl'sriis*iriiittr''
;1;;;" nci provide iriurnatirn a5o$t the edster:ce of a c?sabil.itii sa*lcular
accorT:rilodaiion, or whether aceernmodation 'is mecessanl" Un*n*
'uuu"u
*"t
"o
adciressed at a later staqie to the *xteni permitted L]y iaw'
xye. rxo ril"r.q.*"#JlifrffiL"J,,1r;:#*
Driver's license number required if driving may be required in the
job for which You are aPPlYing:
Iv.r ENo
Ifno, please exPlain:
Have you submitted an application here before?......f]Y.t Ixo
Ifyes, give date(s) and position(s):
Have you ever been employed here before? ' E ytt I Xo
Ifyes, give dates: From / / l' / /
State
Is this application a request for reemployment
following an extended military leave of absence
from this comPanY?..... E Ytt I No
If yes, additional information maybe requested'
Are you 1ega1ly eiigible for employment
in this country?.'....'...'...'.'.. [l yts E No
Date available for work....
What is your desired salary range or hourly rate of pay?
" Pet'''''-.-.......-'.-......'-''.....---'-''-
Type of employment desired: E pt'l1-Ti-e E Part-Time
E Educationai Co-Op E Seasonal E Te*po'uty
Will you relocate if job requires it? """""""" E yts E No
Will you travel if job requires it? ..""""""""' """""""tr Yes E No
If they have been explained to you, are you able to meet the
attendance requirements of the position? "' E Ni A E Yes E No
Haveyoueverbeenbonded? EYes ENo
:nslvering "yes"'tE tiie fo!.t*w1ng question d$es rxsl a*i!'titu!* fir! aut$$:iti' i:'41't*
-*pi-y*i"*. Factsrs such as daie'cf the offense' seriousness *llri naiure of ilie
U*L*ion, rehabiiitation ai:d p*lit'ion a;:rp[ied far urii[ ile taken i:]to
'rc'*L!rit"
Have you ever pleaded'guilry" or "no contest" to
;';;#;";;iJorucrime?...'..'..'.' """Ives Iiso
Ifyes, please provide date(s) and details:
Have you entered into an agreement with any former employer or
other party (such as a noncompetition agreement) that might' in any
*uy, ,.u.io your ability to *o.k fo. ouriompany?"""" E yet E No
Ari reui{L Srp*ftT{-lN?rY E}4PLsYEft Fage 1

2. Starting with Your most recent employer provide the following information
Employer
Telephone f
street address
Cjty
Starting job titte/finatjob titie
I*.di.t".rp.ruitot and title (for most recent position held)
Why did you leave?
ffi*i^ th. typu of work performed and job responsibi[ties'
Dates emptoyed
Commission/Bonus/0ther Compensation
!
$
t
$
Commission/Bonus/0ther Compensation
What did you [jke most about your position?
What were the things you [iked teast about the posjtion?
EmpLoyer
Street address
Starting job title/final job tjtle
I*.di.tu rrp.tito, and title (for most recent posjtion hetd)
Why did you leave?
Summarize the type of work performed and job responsibilities'
Dates employed:
Commission/Bonus/0ther Compensation
Comm jssion/Bonus/other Compensation
!
$
What did you like most about your position?
What were the things you tiked least about the positjon?
Emptoyer
Street address
Starting job tjtte/finai job title
Imediate supervisor and title (for most recent position heLd)
WhV did you teavel
Dates emploved:
Commission/Bonus/0ther Compensation
Commission/Bonus/0ther Compensation
q
$
T
$
Summarjze the type of work performed and job responsibilities'
What did you like most aboui your positjon?
What were the thi.gs you iiked least about the position?
Em ptoyer
Street address
Stadjng job titLe/finaljob title
Why did you ieave?
Tetephone I
Dates employed:
Commission/Bonus/other Iompensation
I
$
Immediate supervisor and tjtle (for most recent position held)
Summarize the type of work performed and j0b responsibitities'
What were the thinqs you tiked ieast about the position?
Page 2
Commissjon/Bonus/0ther Compensation
What did you like most about your position?

3. Explain any gaps in your employment, other than those due to personal illness' injury or disability'
Ive. Ixo
Ifnot addressed on Previous Page, have you ever been fired or asked to resign from a job?""""""'
Ifyes, please exPlain:
ficatesthatmayassistyouinperformingthepositionforwhichyouareapp1ying:
Computer Skills (Check appropriate boxes' Inctude software tittes and years of experience.)
I Word Processing Years: E Internet
Years:
Years:
Years:
[-l Soreadsheet
E Presentation
DE-mail
I other
E Other
D Other
Years:
Years:
Years:
Years:
school attended, the following information.
List names and telePhone
Ifnot applicable, list three
numbers of three business/work references who are
school or personal references who are notrelatedto
not reated to you and are not previous supervlsors'
you.
SS#
We will use this information efforts to safeguard your privacy.
only for employment purposes and make reasonable
Page 3

4. To what job-related organizations
Exclude n'rernbershiS:s that wcutd revear'
veteranfir:serue, llati*nal iiuard err any
(professional, trade, etc.) do You belong?
inforn'l*ticrn" eitiz*rrship' a9e, nres:ti:l rrr phl,sir:aL riisabiijties'
rac*, sol'oi'" r*r"igi*n, sex,
*tirer sirn'ilartY Prot*eted
r;ationat origin, geri*tie
status.
List special accompiishments' publications' awards' etc'
Excturi* iE:f*r.rnatisn thet r",",autd. reveat *:;=, ,YiT;,:--i:y::":;:r-$]fl:1 *rlgin
ii#;;l;;;;,ve,-i*ati*na[ Guard or anv ckl'rer simitartv rro,'*ated status'
genetic ii:forrnati*n, citlz*nsi:lp, a**' i:lental r'r ohysis;ai disai:iiiti*s'
you ever written instructions or directions to be followed by employees or customers?
In your current or a previous job' have
I Yes n Xo I Xot APPiicable
Ifyes, please exPlain:
Is there any other job-related information you want us to know about you?
I certi8/ that all information I have provided in order to apply for and secure work with this emP]oyer iS tlue, complete and correct.
non-defamatorY information, in
from consideratio, ro,.-ptoy-1"'""o'"u"yi"";tiiult"d by applicabie local' state or federal law'
I understand that this apprication remains current for onry 30 days. At th.e concrusion ofthat time, ifI have not heard from the employer and still wish to be considered for
ernployment, it will be necessar;;;;i;;;;diy and flli out a new application
right to t
terminate my
time, with or without cause and with or without ..;+L^,,+ -prior y;^r n^notice, ri.e and an. the employer reserves the same I understand that I am free to resign at any Il I am hired, ".i,rr,",
," impried oiat or w.iti"n ug.ee-"nts contrury to th" fJr.going ."pr.., tunguug. ur. uuli;'ii"ss they are in writing and signed by the employer's president'
:r::::ff;".:].o|],,}i":Xill*ror ai.arminit:ilil ,
"*pl"yment
practices. No question on this application.isused ror the purpose-orlimiting or excluding an
citizenship, genetic informar6r, ug", disability, or any "th"r;;;t;;;.totoJ.
r*u-pt", of p;;tbt,;;;;"rsment include, but are not limited to' unwelcome physical
Harassment of oo.
"-ploy"""
iJ ,iiictly prohibited, whether it is committ'ed by a manager, coworker] subordinate, or noremployee (such as a vendor or customer)'
The Company tat ".
ult .o*ptuirts oiliu'.u..-"t, ,",it"rv ""i 'iitomplaints
will be investigated promptly and thoroughly'
DoNoTSIGNI.INTILYoUHAVEREADTHEABovEAPPLICANTSTATEMENT.
I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
Signature of APPlicant
o2O'13 ComPIYRight
A2163 English Three easy ways to reorder: gneil'corn ' hrdirect'com ' 800-999-911f
Paqe 4
Date

5. ,$#ffi)
,i*l*P..,ti
' Q.:l:14 '
Senior Services
IIF,E!---E] s form' coPY oi
Missouri Department of Health and
Family Care SafetY RegistrY
WORKER REGISTRATION
So.iai Secu rity cail;nO payrnent to Missouri Dept' of Ht^1lth
-'.1d^ -- P0 Box 570, Jefferson CitY, M0 6510^2^'
column on right
Long Term Care / Personal Care
Subiateqories (Complete if LTC/PC selected at left )
tr
tr
tr
tr
D
tr
Adoptive Parent (AgencY Name:
Child Care
Foster ParenVFamily Member of Foster Parent (County Office:
Hospital
f-oni i"r, Care/Personal Care (P/ease choose subcategory at right )')
Menlal Health/Psychiatric Hospital
if no other registration type applies')
-)
E Adult Day Care
n Assisted Living FacilitY
n Hospice
n Hospital LTAC/Swing Bed
fl Mental Health - Residential Facility/lCF
E Nursing Facility/Skilled Nursing
n Personal Care - Home Health
n Personal Care - ln-Home Services
n Personal Care - Consumer Directed
Services/Center for lndependent Living
n Personal Care - HCY/PDWDDD/Other
R one-time registration fee of $11.00 applies to all categories except Foster
Parents.FosterParentsmustlisttheChildren,sDivisioncountyoffice.
@lready register-ed, c.heck our
Register onlY once. 'ii ,nn ,nu/.rofen/fcsr or call, toll free, 866-722 ilZ
il copy oi card with form
X (Jr., Sr., ll, lll)
, list first and last names,
uCuPNt tIf nAtC/ fI IrNrrF'.O/nRrvMrAA TI IrOvNr! st office box' This address mtiai 5E aiii6r;il6 ployer Address.)
PHONE
)
eittrer tett or right column, not both.
No Emplover, because I am
ialchild care term care or mental health care em
Adoptive Parent
Foster Parent/FamilY Member
Home Child Care Provider
Private Pay/Private DutY
Student
Volunteer
Other (Explain: )
tr
T
tr
tr
T
tr
f,
THE BRAUN HOME
506 WEST HACKBERRY
FAYETTE
660)248 -3333 STEPHANIE BRAND ASSISTANT DIRECTOR
raw to process this request. Furrhermore, r authorize '+^,it
jr?ji,:?:"^,lj^t11.T:: l1T iJ'"9:jr::'iltli,ltTl' :,il:":;:'.',,.xxg;'d1}J::rt[:11?ii
iil,:r1:ffiL'Jlsoliffili'iliSii[%"d,[i:?"JifiJ i:##t:;tiq,"]::i+1ryfl***t.::;:t',*:"'*:'10 e21' subsection 1' subdivisions (1) and (2)'
.emptoyment RSMo. For purposes of the FCSR,
prrpoi*'; incrrJdi direct
"rpiov-oLrpioyee'relationship!'
prospective employer/employee relationships'
and screening and interviewing of persons or facitities.iy-tnor. i.rsgnr *nt.rpriting tnl piacement ot an.indiviouat in a child care, elder care or personal
care setting. I understand thal if I dispute the informati-o'n
"".trii.r"o
in the FCSR r'-na-re tnJ rignt to appeal the accuracy of the transfer of information to the
FEsn *iini" thirty (30) days of receiving the results of the background screening.
NOTIGE: The FCSR may choose to deposit the check enclosed etectronically as an ACH debit entry to my designated bank account' I understand that my
signature berow authorize. il-r''";iLri;'tiiution to o"o,:ll!la1il"::::':fl3::::, :lt:?:l.,:I51 3"tli:;15#i,'#:':JffiXXffi ffi"?" ;J?1il,:ffi;:#jilff];;|jffi ;;"1";1"".r,.r**.,e inroimation resarding my account, mv obrisationlo the DHSS will remain unpaid and rurther
nnrcniinnactionmavnetarenovin"oHssoritssubcontractor,including,butnotlimitedto,r9t-tllrfe9.9lEci-f.e-e-s.'.-- ---.-----".--.--.----------'--'-
ust be siqned in blue o1
Rev.09/13

6. H:?]J?rH=,=t:fl]lx":f,ffirPArr:iifi,!,LtJfo"r1n" ,,:::y:g:i,nment of Hearth and seniorservice? (D-!!-sl;lrovides fami,es
and emproyers with a meiliod io obtain a"lgpril-r;i";.i.s inrormationl ine-negistry, through various state agencies' offers several
resources to screen cnifO care, long term care and mental health workers:
o state criminal history and sex offender registry records maintatned by the Mlssouri state Highway Patrol
. child abuse/neglect records maintained o"ylr]6 vrstorrl Departrhent of social services
. mrinialnJ tn" triffii Department of Health and Senior _.nior services
ov . The Employee Disqualification r-irt of Mental Health
The Employee Disqualification Registry *rintrinlo by the Missouri Department . in" vtltto'ri Department of Health and Senior Services
Child care facility licensing records *'ini'in"JoV . of social services
Foster prr"nt |..foro. maintained by the Missouri Department January 1'.2002 as a personal
HT?#: r1.Tr"Jt"t-:llr"r"r., ,,ool,1, a chird care, *g,l[:i.:1.:rd"r carti worker, hired gn or after 1,2009 al l r"nGin""rtn *o*"i]""r-Jio,o"a in'szro-s06,-niMo' is required to make application
care worker, or hired on January such person who rails to
ror registration in the .#oi rr'-atter i# srr6tv'negisfi i,itnin nrt""n (15) da;;:l ii;"i"J.;iig o-iL*irovn."nt ;'Hi"i ;iil;;; s;; ;;1""; nv tii" itpartment' is guiltv of a class B
submit a compreted resisiration form to.the feder"tyl&;':;;;;;i";;"iiti"" i;Jo nEournro to register with the FCSR'
Emproyels and vorunteers from non-state and/or misdemeanor. "L r'iof worker rr no other
H3"Y,,.:flIffiy:bflf:ffi1!ijtJii*1il"t301:13*' ror vour !919r resistration,thut eatesory iot ??"to register 11?"'ibes *itn'tn" Famiry care safety Registry
,,Voruntary.,, (A "voruntary ,."girtiuni; is a person wno is mandated type appries, serect
oursuantto52l0.e00efseq.,RSMo.) rrVou.nl?iJ;ffi?,I*c"-lp;';;;;ie";;'pleasei/somakeoneormoreselectionsfromthe
Lolumn on thL right for subcategory'
you security number pursuant to 19csR 30-80'030(1)' This identifying information'
your Sociar Securitv Number - must provide Sociar i", screenings for the resource
security number, wir be used iriJi."iiaentification ;;ip;; to conduct background incruding sociar "tJ intormat'ion listed in paragraph one above'
with your last.name' List any other
personal Information - List your current,Last Name, First Name, Middle Name, and any suffix associated -have
names by which you may
been known, in"rloing maiden n.*"r,ir.i marriei names, ,no-ni&nrr"s (attach additional sheets if
needed). For identiflcai',Ji p"ptt"t' list your gender and date of birth'
contact lnformation _ List your address including street address or post office box, city, state, ZIP code, and county' lnclude your telephone
number. we wi, use tniili,rormation to notirv vo'gr-oil;;i:i;ffi;tlit;;;J;tt backsround screeninss conducted'
Reoistration Aoreement - sign and date the registration form. your signature will authorize the Family care safety Registry to conduct the
background screening i*,iJBi ,'szroioi.z i5ffi;;i;'prorio. tn! inio*ution to requesters for emplovment purposes' as provided in
$210.921.1, RSMo.
Emolover Associated with this Reoistratio-n-- lf you are currently employed by or are seeking employment with a child care or long term care
provider, prease rist tne;citity name, address, t"[Jni.J "r.i6"i,
Jno'.o].ii.ip.tton' rt rJglstration is not for employment purposes' make
a selection from column on right'
B,Jf}il:ffi5}i.#tf-??J,.S?]i'ri.i.:ilg:..,j:, ?::i::l card and required ree.to the Missouri Department or Hearth and
Senior services, Famiri care safetyRegi*y;;:5] ;";;ro, J"r.*"titv, ilo,Eroz. tt you nave questions, prease carl the Registry
uing th" tof f -free telepho ne n um ber, 866-422-687 2'
WHENWILLIKNowTHERESULTSoFMYBAoKGRoUNDSCREENING?
After the background screening has been **pi"t"o, vo, *irr o1 n,gti[J in *riting of the resurts that wi' be recorded in the Family care
safety Resistry. you ;ili;;; ;" ;;tifled in *riii;;';;;fi time backsrou.;r;;;;"i;; information is provided The notirication will contain the
name and address of the person who made.th" lir"rt ,.0 ilre oicr<giJnJintoriration disctosli' The person making the request will be
informed that informati'on-*itt o" reteased for employment purposes qily:.qF;1 t" siiogii.'1, RSMo' Any person using Registry
information for any other purpose is guirty of a crass b misdemeanor. tn aobition, state agencies can request information for licensure or
regutatory purposes. iri..[]J oi""roring intorrrii;;, ,h" R"s',ttv ol]:lns'tne name and aolress tf tne requester' and determines that the
request is for emproyment or reguratory.purposes. To ensure you receivJ tn"." notincrtions' it wltioe impoi'tant for you to notify the Family
care safety Registry when you hqrle a
"nrng"
iilori;"i;d loJr"r". il ;;; send address cnanges to Famity caie safetv Registry' P'o'
a.r1io l;ff"..ion bitY, rucj, ostoz'
WHATIFIDoN.TAGREEWITHTHERESULTSoFMYBACKGRoUNDSCREENTNG?
As provided in s210.9.12, RSMo, you trave tne-rlgti to
"pp""L
tn" intormuiion transferred to the Familv care safety Registry' Your right to
appeat is timited to tne accuiacy' of the transfe, oiiniorrriion from the .ffi;;;il t''i 'uint'lntlne
bacrgro'nd information and does not
incrude a right to appear the acturacy or fi.,e suisian-ce J.rre inrormation tranlrerred' nn appeai-must be liied in wrlting to the office of the
Director, Missouri Department of Hearth uno !:*r, s;ilr, p.o B;; i7o, J"tr"i.on ciiv, rr'ro, 0s102' within 30 days of receiving the
resurts of the background screening oeterminJtion. nn aoministrative apieai ilialL ue t"t *itl'tin so oays ot the filing of the appeal and a
decision sha, be made within 60 days. rnis risiil a;;";ii; i;;;aitionlS",nv otr,er appear rights sranted bv state law'
WHAT INFORMATION WILL BE DISCLOSED BY THE FAMILY CARE SAFETY REGISTRY?
Disclosure of background information on "
p"rIJn ,egistered in tne ramiry Care satety negistry will be limited' A Registry worker will flrst
person's name
i" i"r.on i, ,egi.i"*d, the Registry-worker will disclose whether the confirm whether the person in question ,.eglsie-reo.-ii1i," RiM;,;nJ'riro, *r,i"h one(s)' specific information will be
is risted in any of the background checks pur"r"nt tosircj.9o3, suuse]ci;;;; disclosed by the Regisffii'"'""t io SZr O gZt
subsection 1' subdivision (2)'
'
Rev. 09/1 3
MO s80-2421 (FP)