Employment Application — The Berhe Group

Form 1 of 4 — Job Requirements Acknowledgment

Position requirements

Berhe Group Homes, Inc. requires child care workers, senior child care workers, assistant managers, and facility managers to be physically and legally able to perform the duties below. Please review carefully before continuing.

Position applying for

Position title*

Please select the position you are applying for.

Preferred home or facility

Physical requirements

Active physical job — walk, bend, crouch or kneel, reach above head
Lift up to forty (40) pounds
Turn and bend at the waist
Go up and down stairs
Drive facility van

Skill requirements

Proficiency in reading, writing, and speaking English
Current First Aid and CPR
Ability to work as a team member

Legal requirements

Fingerprint clearance through California Department of Justice and FBI
Pre-employment physical and TB test
Current DMV printout (cannot be older than 30 days)
Right to work in the United States — I-9 form and documentation within three days of employment

Additional requirements

Completion of 8 hours of orientation training
First-year employees: 40 hours of training; continuing employees: 20 hours each year
Crisis Prevention Intervention (CPI) certification — provided by Berhe Group Homes, Inc.

I understand and am able to meet the above-referenced requirements for the position I am applying for. I authorize Berhe Group Homes, Inc. to verify my qualifications as part of the hiring process.

Form 2 of 4 — LIC 501 Personnel Record · Sections 1 & 2

Personal information

Required by the California Department of Social Services for all employees of licensed residential facilities.

Your information is transmitted over an encrypted connection and emailed only to berhegroup@gmail.com. SSN is voluntary at this stage and used solely for ID verification.

1 — Personal

Last name*

Last name is required.

First name*

First name is required.

Middle name

Mailing address*

Address is required.

Telephone*

Phone number is required.

Email*

A valid email is required.

Social Security Number voluntary, for ID only

Date of birth*

Date of birth is required.

Date of last physical examination

Date of last TB test

Are you 18 years of age or older?*

Yes No

Please answer this question.

Have you ever been employed under a different name?*

No Yes

Driver's license

Do you possess a valid California driver's license?*

Yes No

Please answer this question.

CDL number

Has your driver's license ever been suspended or revoked?*

No Yes

Nearest living relative

Name*

Required.

Relationship*

Required.

Telephone*

Required.

Address

2 — Position

Desired salary or hourly rate

Earliest start date

Form 2 of 4 — LIC 501 Personnel Record · Sections 3-6

Employment, education & references

Tell us about your work history, education, and three people who can speak to your background and abilities.

3 — Previous employment

List most recent experience first. You can add more entries as needed.

Employer 1 — Most recent

Employer name & address

Telephone

Job title & type of work

Reason for leaving

From (month/year)

To (month/year)

4 — Education

Did you receive a high school diploma?

Yes No GED

Currently enrolled in high school completion course?

No Yes

Colleges, universities, or vocational schools

School 1

School name & address

Major / subject

Years completed

Diploma / degree / certificate

Date completed

5 — References

List three people who can speak to your background, character, and abilities. They should not be relatives.

Reference 1

Name*

Required.

Relationship*

Required.

Telephone*

Required.

Address

Reference 2

Name*

Required.

Relationship*

Required.

Telephone*

Required.

Address

Reference 3

Name*

Required.

Relationship*

Required.

Telephone*

Required.

Address

6 — Professional & technical qualifications

Licenses or certificates of competence held

Professional associations

Additional notes

Form 3 of 4 — LIC 508 Out-of-State Disclosure

Out-of-state residence disclosure

California Department of Social Services requires disclosure of any state of residence outside California within the past five (5) years.

Driver's license / I.D. number*

Required.

Issuing state*

Required.

Have you lived in a state other than California within the last five years?*

No Yes

Please answer this question.

Privacy notice acknowledgment

Collection & use of personal information

The California Justice Information Services (CJIS) Division in the Department of Justice (DOJ) and the Care Provider Management Branch (CPMB) in the California Department of Social Services (CDSS) collect this information as authorized by Penal Code §§ 11100-11112; Health and Safety Code §§ 1522, 1522.1, 1569.10-1569.24, 1596.80-1596.879; Family Code §§ 8700-87200; Welfare and Institutions Code §§ 16500-16523.1; and other state statutes and regulations.

The CJIS Division uses this information to determine suitability for employment or volunteer work with children, the elderly, or persons with disabilities; or for licensing, certification, or permit purposes.

Federal Privacy Act statement

Your fingerprints will be used to check the criminal history records of the FBI under 28 U.S.C. § 534. Providing your fingerprints is voluntary; failure to do so may affect approval of your application. Your information may be retained in the FBI's Next Generation Identification (NGI) system.

If you have a criminal history record, the officials making a suitability determination must provide you the opportunity to complete or challenge the accuracy of the information. Procedures for challenging an FBI identification record are set forth in 28 CFR § 16.34.

I have read and acknowledge the Privacy Notice and Federal Privacy Act statement above. I declare under penalty of perjury under the laws of the State of California that the information I have provided is true and correct to the best of my knowledge.

Form 4 of 4 — Reference Authorization & Final Certification

Review, sign & submit

Please review your information below and provide your signature to authorize background and reference verification.

Reference authorization

I hereby authorize the release of personnel information from my prior employers and references only as it relates to the attached Reference Check Form. I authorize Berhe Group Homes, Inc. to contact the references and prior employers I have provided to verify employment, performance, and character.

Certification

I hereby certify under penalty of perjury that the above statements are true and correct. I give my permission for any necessary verification of the information I have provided. I understand that false statements may disqualify me from employment or result in dismissal.

Electronic signature

Sign with your mouse, finger, or stylus in the box below.

Sign here

Type your full name*

Please type your full legal name.

Date*

Required.

Join our team of caregivers and changemakers.

Position requirements

Position applying for

Physical requirements

Skill requirements

Legal requirements

Additional requirements

Personal information

1 — Personal

Driver's license

Nearest living relative

2 — Position

Employment, education & references

3 — Previous employment

4 — Education

5 — References

6 — Professional & technical qualifications

Out-of-state residence disclosure

Privacy notice acknowledgment

Collection & use of personal information

Federal Privacy Act statement

Review, sign & submit

Reference authorization

Certification

Electronic signature

Submitting your application…

Application received. Thank you.

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