Apply Now - Centerlight Home Care

Join Our Compassionate Team

Apply for a Rewarding Career at Centerlight Home Care

Embark on a rewarding career journey with CenterLight Home Care by applying now! We invite dedicated individuals to join our compassionate team, where every day is an opportunity to make a meaningful impact in the lives of those we serve. As a part of CenterLight, you'll not only contribute to the well-being of others but also find a supportive and collaborative work environment that values your skills and dedication. Join us in fostering independence, building connections, and creating positive experiences. Your career with CenterLight Home Care is not just a job; it's a fulfilling journey where you can make a difference and be part of a community that cares.

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- Step 1 of 15

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DSP Hiring Packet Checklist

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Item from Applicant

Fingerprint (FBI/BCl)

Completed

Fingerprint (FBI/BCl) (Completed)

Employer Followup

Rapback Enroliment

Completed

Fingerprint (FBI/BCl) (Completed)

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Orientation

Orientation (Completed)

ISP Training Xoomia Training

Orientation (Completed)

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2 Forms of ID

2 forms ID (Completed)

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Application

Application (Completed)

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W4 (Completed)

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I-9

1-9 (Completed)

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2 Reference Checks

2 Reference Checks (Completed)

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High school Diploma or GED

High school Diploma or GED (Completed)

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6 point + 1 point Excel

6 point + 1 point Excel (Completed)

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8 Hr DODD Training

8 Hr DODD Training (Completed)

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Med Pass

Med Pass (Completed)

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CPR

CPR (Completed)

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Xoomia Account

Xoomia Account (Completed)

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Drivers abstract

Drivers abstract (Completed)

File Upload

Click or drag files to this area to upload. You can upload up to 10 files.

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Reviewed By:

Date:

CENTERLIGHT HOME CARE, LLC.

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Date of Application:

(Office Use Only) Hire Date:

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Name:

First

Middle

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Current Address:

City

State

Zip Code

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Home Number:

Cell Number:

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Social Security Number:

Date of Birth:

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Are you CPR/First Aid certified?

Expiration Date:

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Do you have Med-Pass certification?

Expiration Date:

Other Certifications?

Driver’s License Information:

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State:

License #:

Expiration Date:

Have you ever been convicted of a crime or are any felony charges pending against you?

Explain

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Can you effectively communicate with the individual receiving services?

Are you legally able to work in the United States?

Have you ever had any Professional License or Certification placed under investigation, revoked, disciplined, or suspended?

Can you perform the required duties of the job in which you are applying for?

Do you have reliable transportation to work?

Able to read, write and understand English?

Do you have DSP experience?

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Date available to work:

Hours needed:

Shift preference: (please circle one or more)

First
Second
Third
Any

Days you are available: Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Person to notify in case of an emergency:

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Name

.

Contact #

Relationship

Employment History

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Dates Employed: From

Reason for Leaving:

Facility/Company:

Phone:

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Street Address:

City

State

Zip Code

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Position Held:

Pay Rate(s):

Reference Checked:

Supervisor’s Name and Title

Duties:

Date

Employment History - Option 2

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Dates Employed: From

Reason for Leaving:

Facility/Company:

Phone:

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Street Address:

City

State

Zip Code

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Position Held:

Pay Rate(s):

Reference Checked:

Supervisor’s Name and Title

Duties:

Date

Education History

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Education

High School

College

Other School

Name & Location of School

High School Name

College Name

Other School Name

Diplomas, Degrees Received

High School Diploma/Degree

College Diploma/Degree

Other School Diploma/Degree

Authorization

“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.
This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.”

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Signature

.

Date

Employment Reference Verification Form

The following information is required to work as a direct care worker with Centerlight Home Care LLC

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Name

Date

I have worked as a Direct Support Professional for at least one year?

If yes, Name of Agency or Facility

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Start Date

End Date

Phone Number

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How was this verified

In Person

By Phone

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In writing (mail or fax)

By Email

Three (3) Personal References (non family members)

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Name & Relationship

How was this verified

Telephone Contact

In Person

How was it Verified

By Phone

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In writing (mail or fax)

By Email

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Name & Relationship

How was this verified

Telephone Contact

In Person

How was it Verified

By Phone

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In writing (mail or fax)

By Email

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Name & Relationship

How was this verified

Telephone Contact

In Person

How was it Verified

By Phone

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In writing (mail or fax)

By Email

Statement of Truth & Responsibility

By Signing this form, I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment with Centerlight Home Care LLC, I understand that false or misleading information contained in this application or provided in the interview process may result in my immediate release.

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Applicant Signature

Date

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Supervisor Signature

.

Date

Residency Verification

Have you lived in Ohio in the past 5 years (can you prove 5 year residency)?
Yes (BCII required) or No (FBS required) ,

According to the Ohio Revised Code 5123:2-2-02 6A

If an applicant does not present proof that he or she has been a resident of Ohio for 5123:2-2-02 4 the five-year period immediately prior to the date upon which the criminal records check is requested, the responsible entity shall request that the bureau of criminal identification and investigation obtain information from the federal bureau of investigation as part of the criminal records check.

If an applicant presents proof that he or she has been a resident of Ohio for the five-year period immediately prior to the date upon which the criminal records check is requested, the responsible entity may request that the bureau of criminal identification and investigation obtain information from the federal bureau of investigation as part of the criminal records check.

For purposes of this paragraph, an applicant may provide proof of Ohio residency by presenting, with a notarized statement asserting that he or she has been a resident of Ohio for that five-year period, a valid driver's license, notification of registration as an elector, a copy of an officially filed federal or state tax form identifying the applicant's permanent residence, or any other document the responsible _entity considers acceptable.

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Applicant Name

Date

Proof/Evidence Shown

Notary Statement;

Must be in writing, under oath

The undersigned, being first duly sworn, deposes and says all of the answers entered on this form are true and correct.

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Applicant Signature

Date

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Notary Signature:

.

Date

W-4 Employee’s Withholding Certificate OMB No. 1545-0074

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
Department of the Treasury Give Form W-4 to your employer. 2 © 23

Internal Revenue Service Your withholding is subject to review by the IRS.

Name

First

Last

Address

City or town, state, and ZIP code

Single or Married filing separately
Married filing jointly or Qualifying surviving spouse
Head of household (Check only if you're unmarried and Pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Complete Steps 2-4 ONLY if they apply to you; otherwise, skip to Step 5. See page.2 for more information on each step, who can
claim exemption from withholding, other details, and privacy.

Step 2: Complete this step if you (1) hold more than one job ata time, or (2) are married filing jointly and your spouse
Multiple Jobs also works. The correct amount of withholding depends on income eafned from all of these jobs.

or Spouse Do only one of the following.

Works (a) Reserved for future use.

(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below; or

(c) 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 generally more accurate than (b) if pay at the lower paying job is more than half of the pay at the
higher paying job. Otherwise, (b) is more accurate .

TIP: If you have self-employment income, see page 2.

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 for qualifying children and other dependents. You may add to
this the amount of any other.credits.

(a) Other income (not from jobs). If you want tax withheld for other income you
(optional): expect this year that won't have withholding, enter the amount of other income here.

This may include interest, dividends, andretirement income

(b) 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

Under penaities of perjury, ! declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

Employers Only

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Employer's name and address

.

First date of employment

Employer identification number (EIN)

I-9 Form Employment Eligibility Verification USCIS Department of Homeland Security

U.S. Citizenship and Immigration Services

> START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: it is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an
employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the
documentation presented has a future expiration date may also constitute illegal discrimination.

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Last Name (Family Name}

Middle Initial

Address (Street Number and Name)

City or Town

ZIP Code

U.S. Social Security Number

First Name (Given Name)

Other Last Names Used (if any)

Apt. Number

State

Date of Birth (mm/do/yyyy)

Employee's E-mail Address

Employee’s Telephone Number

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

| attest, under penalty of perjury, that | am (check one of the following boxes}:

1.A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident (Alien Registration Nurnber/USCIS Number):
4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): Some aliens may write "N/A" in the expiration date field. (See instructions)

Aliens authorized to work must provide only one of the following document numbers to complete Form 1-9: An Alien Registration Number/USCIS Number OR Form 1-94 Admission. Number OR Foreign Passport Number.

Alien Registration Number/USCIS Nurnber:

Form |-94 Admission Number:

Foreign Passport Number:

Country of issuance:

attest, under penalty of perjury, that | have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

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Signature of Preparer or Translator

Last Name (Family Name)

Today's Date (mm/dd/yyyy)

First Name (Given Name)

Address (Street Number and Name)

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City or Town

.

State

ZIP Code

Direct Deposit Authorization Form

Please print and complete ALL the information below.

Name:

Address:

City, State, Zip:

Name of Bank:

Account #:

9-Digit Routing #

Amount

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check

Entire Paycheck

Type of Account:

Checking
Savings

Attach a voided check for each bank account to which funds should be deposited (if necessary)

Centerlight Home Care, LLc [Company Name] is hereby authorized to directly deposit my pay to the account listed above. This authorization will remain in effect until I modify or cancel it in writing.

Signature

Date

.

Attestation and Agreement to Notify Employer

I hereby attest that I have not: 1) been convicted of, 2) pleaded guilty to, or 3) been found eligible for intervention in lieu of conviction, for any of the disqualifying offenses listed below and agree that I will notify my employer "CenterLight Home Care LLc", within 14 calendar days, if while employed, I am formally charged with, am convicted of, plead guilty to, or am found eligible for intervention in lieu of conviction for any of the disqualifying offenses. I understand that failure to make this notification may result in termination of employment.

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(Employer's Name)

(Date Signed)

(Applicant's Signature)

(Applicant's Name Printed)

Tier 1 Disqualifying Offenses (Permanent Exclusion):

2903.01 (aggravated murder)
2903.02 (murder)
2903.03 (voluntary manslaughter)
2903.11 (felonious assault)
2903.15 (permitting child abuse)
2903.16 (failing to provide for a functionally impaired person)
2903.34 (patient abuse and neglect)
2903.341 (patient endangerment)
2905.01 (kidnapping)
2905.02 (abduction)
2905.32 (human trafficking)
2905.33 (unlawful conduct with respect to documents)
2907.02 (rape)
2907.03 (sexual battery)
2907.04 (uniawful sexual conduct with a minor, formerly corruption of a minor)
2907.05 (gross sexual imposition)
2907.06 (sexual imposition)
2907.07 (importuning)
2907.08 (voyeurism)
2907.12 (felonious sexual penetration)
2907.31 (disseminating matter harmful te juveniles)
2907.32 (pandering obscenity)
2907.321 (pandering obscenity involving a minor)
2907.322 (pandering Sexually oriented matter involving a minor)
2907.323 (illegal use of minor in nudity-oriented material or performance)
2909.22 (soliciting/providing Support for act of terrorism
2909.23 (making terrorist threat)
2909.24 (terrorism)
2913.40 (Medicaid fraud)
2923.01 (conspiracy) when the underlying offense is any of the offenses or violations on this list
2923.02 (attempt) when the underlying offense is any of the offenses or violations on this list
2923.03 (complicity) when the underlying offense is any of the offenses or violations on this fist

A canviction related to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct
involving a federal or state-funded program, excluding the disqualifying offenses set forth in section 2913.46 of the
Revised Code (illegal use of supplemental nutrition assistance program [SNAP] or women, infants, and children
[WIC] program benefits).

A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States
that is substantially equivalent to any of the offenses or violations on this list.

Tier 2 Disqualifying Offenses (Ten-Year Exclusion):

2903.04 (involuntary manslaughter)
2903.041 (reckless homicide)
2905.04 (child stealing) as it existed prior to July 1, 1996
2905.05 (criminal child enticement)
2905.11 (extortion)
2907.21 (compelling prostitution)
2907.22 (promoting prostitution)
2907.23 (enticement or solicitation to patronize a prostitute, procurement of a prostitute for another)
2909.02 (aggravated arson)
2909.03 (arson)
2911.01 (aggravated robbery)
2911.11 (aggravated burglary)
2913.46 (illegal use of supplemental nutrition assistance program [SNAP] or women, infants, and children [WIC] program benefits)
2913.48 (workers' compensation fraud)
2913.49 (identity fraud)
2917.02 (aggravated riot)
2923.01 (conspiracy) when the underlying offense is any of the offenses or violations on this list
2923.02 (attempt) when the underlying offense is any of the offenses or violations on this list
2923.03 (complicity) when the underlying offense is any of the offenses or violations on this list
2923.12 (carrying concealed weapon)
2923.122 (illegal conveyance or possession of deadly weapon or dangerous ordnance in a school safety zone, illegal possession of an object indistinguishable from a firearm in a school safety zone)
2923.123 (illegal conveyance, possession, or control of deadly weapon or dangerous ordnance into courthouse)
2923.13 (having weapons while under disability)
2923.161 (improperly discharging a firearm at or into a habitation or school)
2923.162 (discharge of firearm on or near prohibited premises)
2923.21 (improperly furnishing firearms to minor)
2923.32 (engaging in pattern of corrupt activity)
2923.42 (participating in criminal gang)
2925.02 (corrupting another with drugs}
2925.03 (trafficking in drugs)
2925.04 (illegal manufacture of drugs or cultivation of marihuana)
2925.041 (illegal assembly or possession of chemicals for the manufacture of drugs}
3716.11 (placing harmful objects in food or confection)

A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.

.

Tier 3 Disqualifying Offenses (Seven-Year Exclusion):

959.13 (cruelty to animals)
959,131 (prohibitions concerning companion animals)
2903.12 (aggravated assault)
2903.21 (aggravated menacing)
2903.211 (menacing by stalking)
2905.12 (coercion)
2909.04 (disrupting public services)
2911,02 (robbery)
2911.12 (burglary)
2913.47 (insurance fraud)
2917.01 (inciting to violence)
2917.03 {riot}
2917.31 (inducing panic}
2919.22 (endangering children)
2919.25 (domestic violence)
2921.03 (intimidation)
2921.11 (perjury)
2921.13 (falsification, falsification in theft offense, falsification to purchase firearm, or falsification to obtain a concealed handgun license)
2921.34 (escape)
2921.35 (aiding escape or resistance to lawful authority)
2921.36 (illegal conveyance of weapons, drugs, or other prohibited items onto grounds of detention facility or institution)
2923.01 (conspiracy) when the underlying offense is any of the offenses or violations on this list
2923.02 (attempt) when the underlying offense is any of the offenses or violations on this list
2923.03 (complicity) when the underlying offense is any of the offenses or violations on this list
2925.05 (funding of drug or marihuana trafficking)
2925.06 {illegal administration or distribution of anabolic steroids}
2925.24 (tampering with drugs)
2927.12 (ethnic intimidation)

A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.

.

Tier 4 Disqualifying Offenses (Five-Year Exclusion):

2903.13 (assault)
2903.22 (menacing)
2907.09 (public indecency)
2907.24 (soliciting after positive human immunodeficiency virus test)
2907.25 (prostitution)
2907.33 (deception to obtain matter harmful to juveniles)
2911.13 (breaking and entering)
2913.02 (theft}
2913.03 (unauthorized use of a vehicle}
2913.04 (unauthorized use of property, computer, cable, or telecommunication property)
2913.05 (telecommunications fraud)
2913.11 (passing bad checks)
2913.21 (misuse of credit cards)
2913.31 (forgery, forging identification cards)
2913.32 (criminal simulation)
2913.41 (defrauding a rental agency or hostelry)
2913.42 (tampering with records}
2913.43 (securing writings by deception)
2913.44 (personating an officer)
2913.441 (unlawful display of law enforcement emblem)
2913.45 (defrauding creditors)
2913.51 (receiving stolen property)
2919.12 (unlawful abortion)
2919.121 (unlawful abortion upon minor)
2919.123 (unlawful distribution of an abortion-inducing drug)
2919.23 (interference with custody}
2919.24 (contributing to unruliness or delinquency of child)
2921.12 (tampering with evidence)
2921.21 (compounding a crime}
2921.24 (disclosure of confidential information)
2921.32 (obstructing justice)
2921.321 (assaulting/harassing police dog or horse/service animal}
2921.51 (impersonation of peace officer)
2923.01 (conspiracy) when the underlying offense is any of the offenses or violations on this list
2923.02 (attempt) when the underlying offense is any of the offenses or violations on this list
2923.03 (complicity) when the underlying offense is any of the offenses or violations on this list
2925.09 (illegal administration, dispensing, distribution, manufacture, possession, selling, or using any dangerous veterinary drug)
2925.11 (drug possession other than a minor drug possession offense)
2925.13 (permitting drug abuse)
2925.22 (deception to obtain dangerous drugs)
2925.23 {illegal processing of drug documents)
2925.36 (illegal dispensing of drug samples)
2925.55 (unlawful purchase of pseudoephedrine product)
2925.56 (unlawful sale of pseudoephedrine product)

A violation of an existing or former municipal ordinance or law of this state, any other state, or the United States that is substantially equivalent to any of the offenses or violations on this list.

.

ISP TRAINING SIGNATURE SHEET

Evidence that the staff person, prior to providing direct services, received training on the ISP including-

What is important to the individual and what is important for the individual.
The individual’s support needs including, as applicable, behavioral support strategy, management of the individual’s funds and medication administration.
Staff must read ISP and sign below. Inform your supervisor of any questionsconcerning services and how to deliver them before you sign.

DSP’s Name

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Individual’s Name

ISP Span Date

Initial

Date of Training

.

REQUEST For a background check Via Electronic fingerprincing

CASH ONLY

BCl $35
FBI $35
Both BCI/FBI $65

Reason for background check / ORC Code:

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Personal info ( Please Print)

Name

Social Security Number

Date of Birth

Address

City/State/Zip

Phone

DL#

Required only if FBI requested:
Mail Background Check Results to address below or Select from list to the right

Sex:

Race:

Height:

Weight:

Eyes:

Hair:

Company Name

Attention

Address

City/State/Zip

Phone

I certify that the Personal identifiers provided on the supplied form is accurate and |voluntarily and knowingly authorize the West Park License Bureau, LLC Web check Agency tosubmit information.to the Ohio Bureau of Criminal identification and Investigations (BCI&1)to disseminate criminal arrest, conviction and juvenile delinquency adjudication records to‘the web check provider or agency | have on this form to receive this information.| voluntarily and knowingly release the Ohio Attorney General's Office, BCI&I, and their employees from‘all claims and liability related to this authorized criminal record review and dissemination. The authorization and waiver is.valid for one year from the date this background check was conducted.

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Applicants Name (print)

Applicants Signature (Date)

Applicants Signature

Parent/Guardian (print)

Parent/Guardian Signature (date)

Parent/Guardian Signature

Checkboxes

By signing this form the applicant acknowledges that all information on this form is accurate. Any mistakes or errors on this form are the responsibility of the applicant .

Join Our Compassionate Team

Apply for a Rewarding Career at Centerlight Home Care

DSP Hiring Packet Checklist

CENTERLIGHT HOME CARE, LLC.

Driver’s License Information:

Person to notify in case of an emergency:

.

.

Employment History

Employment History - Option 2

Education History

Education

Name & Location of School

Diplomas, Degrees Received

Authorization

.

.

.

.

.

Employment Reference Verification Form

Three (3) Personal References (non family members)

Statement of Truth & Responsibility

.

Residency Verification

Notary Statement;

.

.

.

.

W-4 Employee’s Withholding Certificate OMB No. 1545-0074

Employers Only

.

.

.

.

I-9 Form Employment Eligibility Verification USCIS Department of Homeland Security

.

Direct Deposit Authorization Form

Amount

.

.

.

.

.

Attestation and Agreement to Notify Employer

Tier 1 Disqualifying Offenses (Permanent Exclusion):

Tier 2 Disqualifying Offenses (Ten-Year Exclusion):

.

.

Tier 3 Disqualifying Offenses (Seven-Year Exclusion):

.

.

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Tier 4 Disqualifying Offenses (Five-Year Exclusion):

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.

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ISP TRAINING SIGNATURE SHEET

Individual’s Name

ISP Span Date

Initial

Date of Training

.

.

.

.

REQUEST For a background check Via Electronic fingerprincing

Personal info ( Please Print)

Links

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