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Evan Home Care LLC, (the "Company"), is an equal opportunity/affirmative action employer and contractor. All qualified applicants will be considered without regard to age, race, color, sex, religion, nation origin, marital status, ancestry, citizenship, veteran status, sexual orientation or preference, or physical or mental disability



Are you at least 18 years old?
If under 18, do you have a work permit?


Circle Highest Grade Completed

High School:

College, Trade or Business:

Graduate Studies:



Major Studies

Degree, Diploma, License or Certificate

High School


Vocational, Business, Other

List Any Professional Designations and Licenses, including license numbers and expiration dates

Other Special Knowledge, Skills or Qualifications

For Clerical Applicants Only:

Do you type?

If yes, WPM:

Computer Skills (Hadware/Software)

Employment History

List Any Professional Designations and Licenses, including license numbers and expiration dates

List Any Professional Designations and Licenses, including license numbers and expiration dates

List Any Professional Designations and Licenses, including license numbers and expiration dates

List Any Professional Designations and Licenses, including license numbers and expiration dates


May we contact your current employer for references?

If hired as an employee, will you be able to work overtime?.

Will you be able to perform the essential job functions for the position you are applying for with or without reasonable accommodation?

Have you ever been convicted of a crime, excluding misdemeanors and summary offenses, which has not been annulled, expunged or seals by court? (A “yes” response does not automatically disqualify your application.)


The above information is true and correct. I understand that, in the event of my employment by or contract with the Company, I shall be subject to dismissal if any of the information I have given in this application is false or misleading, or if I have failed to give any information herein requested, regardless of the time elapsed after discovery.


I authorize the Company to inquire into my educational, professional and past employment or contract history references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to the Company and will hold the Company and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment or contracting decision was made on the basis of such information.


I understand that nothing in this employment application, the granting of an interview or my subsequent association with the Company, is intended to create an employment contract between myself and the Company, unless a written contract is signed by me and the Company. On the contrary I understand and agree that, if hired/contracted, my employment/contract will be terminable at will and may be terminated by me or the Company at any time and for any reason. I understand that no person has any authority to enter into any agreement contrary to the foregoing.


If employed, I will be required to provide original documents, which verify my identity and right to work in the United States under the Immigration Reform and Control Act (IRCA) of 1986. The document(s) provided will be used for completion of Form I-9.


I hereby acknowledge that I have read and agree to the above statements.

your signature has been submited!




As a staff member of Evan Home Care LLC, (the Agency), I agree that I will:

Hold paramount the safety, health and welfare of the Agency service recipients in the performance of my professional duties.

Treat with respect and consideration all persons, regardless of race, religion, gender, sexual orientation, maternity, marital or family status, disability, age or national origin.

Engage in carrying out the Agency’s Mission in a professional manner.

Demonstrate the highest standards of personal integrity and honesty in all activities

Avoid any interest or activity that is in conflict with the conduct of my obligations to the Agency and the Agency’s recipients.

Respect and protect privileged and confidential information of the Agency and its recipients.

Report any fraud, abuse neglect or other illegal or immoral behavior which would harm or injure any Agency recipient, staff member or the Agency.

Refrain from unethical, illegal or immoral behavior which would harm or injure any Agency recipient, staff member or the Agency.

I also understand that I may not:

Use, for marketing or solicitation purposes, information from any source that identifies recipients receiving waiver services;

Solicit recipients to request services directly or through an agent, through the use of fraud, intimidation, undue influence or any form of overreaching;

Unduly influence a recipient to request a service, select a service Agency, or participate in an activity regardless of whether the recipient’s request results in selection to the Agency;

Compensate a recipient with funds or any item of value for the purposes of inducing the recipient to select the Agency for services or for any matter related to the provision of services.

Receive any financial benefit as a result of being named the beneficiary of a life insurance policy covering a recipient served by the Agency.

Benefit financially by borrowing or otherwise using the personal funds of a recipient served by the Agency.

I agree to uphold the Agency’s Code of Conduct.

your signature has been submited!


Staff Member Name



All staff members of Evan Home Care LLC, (the Agency), will observe the following documentation guidelines

Every page in the record shall be identifiable to a specific recipient and bear the recipient’s name and other Agency identifiable information, such as date of birth, etc.

All recipient record documentation shall only be made on Agency-approved forms and documents.

Every entry in the recipient record must include a complete date (month, day and four-digit year) and a time associated with it.

Entries should be made as soon as possible after an event or observation is made. It is unacceptable for any Agency staff member to document in advance or to back-date an entry.

Entries must authenticated by a signature. At a minimum the signature should include the first initial, last name and title/credential.

Documentation must be authenticated by the staff member who wrote it. A staff member shall never make an entry to a recipient record or sign documentation of service that has been written by someone else

Entries must be made in black pen, in permanent ink. No erasable pen,water-soluble ink or pencil may be used.

Agency staff member notes shall be original documents and not photocopies.

Documentation must be specific and based on facts and observation (i.e., things that are seen, heard, touched, smelled, signs, symptoms) and not in language that is vague or generalized. Examples of vague documentation: “Recipient is doing well” or “Recipient isn’t herself today.” Preferred documentation: “Recipient is alert and oriented to time and place,” or “Recipient exhibits anxious behavior such as pacing for an hour at a time in the early evening, and is agitated and asking about her daughter.”

Documentation must include all facts and pertinent information related to an event, services provided, recipient condition, response to services or information, etc.

Documentation shall not contain abbreviations that are not generally accepted.

If the documentation is not legible by someone other than the author, it must be rewritten by the author on the next available line, by defining what the entry is, referring back to the original documentation and legibly rewriting the entry. Example: "Clarified entry of (date)" and rewrite entry, date and sign. The rewritten documentation must be the same as the original.

Standardized forms may contain questions or fields that do not pertain to a recipient. In those cases, the Agency staff member will indicate that the item is not applicable by writing “N/A” to show that the question was reviewed and answered. All fields should have some entry whether they apply to the recipient or not. Blank fields may be subject to tampering or falsification by others.

When an error is made in a recipient record entry or document, proper error correction procedures must be followed:

Draw line through information (thin pen line). Make sure that the inaccurate information is still legible.

Initial and date the corrected entry.

State the reason for the error (i.e. in the margin or above the note where possible).

Document the correct information. If the error is in a narrative note, it may be necessary to enter the correct information on the
next available line/space documenting the current date and time and referring back to the incorrect entry.

Agency staff members may never obliterate or otherwise alter the original entry by blacking out with marker, using white out, writing over an entry, etc.

I agree to uphold the Agency’s Code of Conduct.

your signature has been submited!


Staff Member Name


Request for Taxpayer Identification Number and Certification

2-Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes

3-Exemptions (codes apply only to certain entities, not individuals)

Exempt payee code (if any):

Exemption from FATCA reporting code (if any)

Address (number, street, and apt. or suite no.)

City, state, and ZIP code

List account number(s) here (optional)

Requester’s name and address (optional)

Employer identification number

Employee’s Withholding Certificate

City, state, and ZIP code

If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld

If your total income will be $200,000 or less ($400,000 or less if married filing jointly)

Multiply the number of qualifying children under age 17 by $2,000

Multiply the number of other dependents by $500

Add the amounts above and enter the total here

Other income (not from jobs). If you want tax withheld for other income you expect this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income

Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here

Extra withholding. Enter any additional tax you want withheld each pay period

If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE
Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.

1- Two jobs. Using the “Higher Paying Job” row and the“Lower Paying Job” column, find the value at the intersection of the two household salaries and enter that value on line 1

2- Three jobs a) Find the amount from the appropriate table on page 4 using the annual wages from the highest paying job in the “Higher Paying Job” row and the annual wages for your next highest paying job in the “Lower Paying Job” column.

2- Three jobs b) Add the annual wages of the two highest paying jobs from line 2a together and use the total as the wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower Paying Job”

2- Add the amounts from lines 2a and 2b and enter the result on line

3- Enter the number of pay periods per year for the highest paying job. For example, if that job pays
weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc.

Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3.


Employer’s name and address

First date of employment

Employer identification number (EIN)

Enter an estimate of your 2022 itemized deductions (from Schedule A (Form 1040)). Such deductions may include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 7.5% of your income


• $25,900 if you’re married filing jointly or qualifying widow(er)

• $19,400 if you’re head of household
• $12,950 if you’re single or married filing separately

If line 1 is greater than line 2, subtract line 2 from line 1 and enter the result here. If line 2 is greater
than line 1, enter “-0-”

Enter an estimate of your student loan interest, deductible IRA contributions, and certain other adjustments (from Part II of Schedule 1 (Form 1040)). See Pub. 505 for more information

Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4


The following acknowledgements apply to all Direct Service Providers and/or Employees, Contract Providers, and Volunteers. Please initial each statement.

I affirm that I have not been designated as a sexual predator pursuant to s. 775.21; a career offender pursuant to s. 775.261; or a sexual offender pursuant to s. 943.0435, unless the requirement to register as a sexual offender has been removed pursuant to s. 943.04354.

I understand that I must acknowledge the existence of any applicable criminal record relating to the above lists of offenses including those under any similar statute of another jurisdiction, regardless of whether or not those records have been sealed or expunged.

I understand that, while employed or volunteering in any position that requires an APD background screening as a condition of employment, I must immediately notify my supervisor/employer of any arrest, any notice of possible criminal prosecution including any violation or infraction mandating a court appearance. Reporting must be done immediately if during normal working hours or
immediately the next business day if after normal working hours


Essential Functions

Provide service to the recipient in accordance with recipient’s Implementation Plan

Assist recipient with:

Ambulation, eating, dressing, shaving, physical transfer

Grooming, including bed, sponge, tub, or shower bath

Shampoo: sink, tub, or bed

Nail (filing, buffing only) and skin care (applying lotion only)

Oral hygiene

Planning, preparing and serving meals, according to the Service Plan

Maintain a neat, clean, safe and healthy environment that includes light cleaning and straightening of the bathroom, straightening of the sleeping and living areas, washing the dishes and laundry, and other tasks to maintain cleanliness

Be able to recognize an emergency situation and follow-up with assistance such as CPR and calling 911

Provide physical and emotional support and maintain respect for the recipient, the recipient’s privacy and property

Observe appearance and gross behavioral changes in the recipient and report to the registered nurse

Turn in visit notes to the Agency office per policy

Provide service in a professional manner at all times and in all situations

Provide Communicate with Agency about any employment problems or concernsin a professional manner at all times and in all situations

Be mature and able to deal effectively with the demands of the job

Comply with in-service training requirements

Communication skills, including speaking, reading and writing legibly in English

Observe, report and document recipient status and the services provided

Comply with infection control regulations and aseptic techniques

Comply with all federal and state rules, regulations, and laws

Comply with all Agency policies and procedures

Other duties and special projects as assigned


Confidentiality Policy and Agreement - I agree to:
▪ Maintain recipient confidentiality according to HIPAA standards and all other healthcare privacy legislation, even after my contract with Evan Home Care LLC is terminated.
▪ Refrain from discussing any recipient’s information or the organization’s business with anyone who does not work with or for Evan Home Care LLC, and who does not have a need to know about the information or business. I will refer any individuals making such inquiries to the Supervisor.
▪ Maintain the confidentiality of trade secrets, confidential or proprietary information regarding the organization’s APD recipients or business.

Employment Eligibility Verification

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number

Alien Registration Number/USCIS Number

Form I-94 Admission Number

Foreign Passport Number

Country of Issuance


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