260-483-6878
Toll-free: 1-877-295-2200
Personal Information

If you cannot be reached at above phone number, where may we contact you?

Employment Desired
Education

High School

College

Vocational/Business

Professional Education

Professional License/Certificates

Licence/Certificate 1

Licence/Certificate 2

Licence/Certificate 3

Licence/Certificate 4

Personal References (No Family members/relatives)

Reference 1

Reference 2

Reference 3

Reference 4

Reference 5

Employment History
List last or present position first

Position 1

Position 2

Position 3

Position 4

Employment Understanding

This Institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used such discrimination.

I voluntarily give this Institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies, or corporations supplying such information. I consent to take the physical examination, and such future physical examinations as may be required by this Institution at such times and place as the Institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination which relates to the essential duties I would be required to perform.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any mistreatment or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification form (I-9) and within three days show satisfactory evidence of identity and eligibility for employment.

I understand that Sunshine’s hiring process is a multistep process and I am not considered an employee until all the steps of the hiring process are successfully completed including signing the employee handbook.

Additional Information

Please note if you are called in for an interview you will be asked to bring a copy of your TB and Physical at that time.

Do you have experience in the following: (Y/N)

Sunshine Criminal History and OIG Exclusion Policy

Indiana law prohibits employment of anyone by a Licensed Home Health Agency or Licensed Personal Service Agency, if that person’s national criminal history background check indicated that the person has been convicted of any of the following:

(1) Rape (IC 35-42-4-1)
(2) Criminal deviate conduct (IC 35-42-4-2)
(3) Exploitation of an endangered adult (IC 35-46-1-12)
(4) Failure to report battery, neglect, or exploitation of an endangered adult (IC 35-46-1-13)
(5) Theft (IC 35-43-4), if the conviction of theft occurred less than ten (10) years before the person’s employment application date
(6) A felony that is substantially equivalent to a felony listed IN:

(A) Subdivision (1) through (4); or
(B) Subdivision (5), if the conviction for theft occurred less than ten (10) years before the person’s employment application date;
For which the conviction was entered in another state.

Sunshine is required to run every applicant’s name through the Office of Inspector General’s Exclusion list. If you are on the exclusion list, Sunshine cannot offer you employment.

Have you ever been convicted of any of the following?

IF YOU ARE APPLYING FOR A FIELD POSITION, PLEASE COMPLETE THE FOLLOWING SECTIONS.  IF YOU ARE APPLYING FOR AN OFFICE ONLY POSITION PLEASE SKIP THE POLICIES AND AVAILABILITY AND HOURS SECTIONS.

Policies

Please take the time to read, understand, and initial each of the following policies:

Enter your initials below to confirm this statement
Enter your initials below to confirm this statement
Enter your initials below to confirm this statement
Enter your initials below to confirm this statement
Enter your initials below to confirm this statement
Availability and Hours

IF YOU ARE SEEKING FULL TIME EMPLOYMENT PLEASE COMPLETE THE FOLLOWING SECTION:

IF YOU ARE SEEKING PART TIME EMPLOYMENT PLEASE COMPLETE THE FOLLOWING SECTION: