Employment Application

1 Section 1 — Personal Information

Last Name *

First Name *

Middle Name / Initial

Street Address *

Apt / Unit #

City *

State

ZIP Code *

Primary Phone *

Alternate Phone

Email Address *

Date of Birth *

Social Security Number *

Are you 18 or older? *

Yes No

Legally authorized to work in the U.S.? *

Yes No

Require visa sponsorship?

Yes No

Valid FL Driver License or Reliable Transportation?

Yes No

Current, valid Auto Insurance?

Yes No

Languages spoken (other than English)

2 Section 2 — Position & Availability

Position(s) Applied For *

HHA CNA RN LPN

Employment Type

Full-Time Part-Time PRN / As-Needed

Date Available to Start *

Desired Hourly Rate

Geographic Area(s) Preferred

3 Section 3 — Employment History

List last three (3) employers. We may contact previous employers unless you indicate otherwise.

Employer #1 (Most Recent)

Employer Name

Phone

City / State

From (mm/yyyy)

To (mm/yyyy)

Position / Title

Supervisor

Reason for Leaving

Employer #2

Employer Name

Phone

City / State

From

To

Position / Title

Supervisor

Reason for Leaving

Employer #3

Employer Name

Phone

City / State

From

To

Position / Title

Supervisor

Reason for Leaving

4 Section 4 — Education & Training

Highest Level of Education *

5 Section 5 — Licenses & Certifications

Required per ss.400.512 F.S.: Provide copies of ALL licenses/certifications. HHAs must provide proof of 40-hour training (Rule 59A-18.0081). All licenses must be current and in good standing.

License / Certification	State	Copy Attached?
FL Nursing License (RN/LPN)	FL	Yes N/A
CNA Certification (FL Registry)	FL	Yes N/A
HHA Training Certificate (40-hr)	FL	Yes N/A
CPR / BLS Certification	—	Yes N/A
First Aid Certification	—	Yes N/A
Other (specify):	—	Yes N/A

6 Section 6 — Professional References

Three (3) professional references required. No relatives. Previous supervisors or clinical instructors preferred.

Reference #1

Full Name

Relationship

Phone

Reference #2

Full Name

Relationship

Phone

Reference #3

Full Name

Relationship

Phone

7 Section 7 — Background Disclosure

Level 2 Background Screening Required: ss.400.512, Chapter 435, and ss.408.809 F.S. All registry workers must submit fingerprints via FDLE-approved Livescan prior to placement.

Ever convicted of or pled guilty/no contest to a felony or misdemeanor (excluding minor traffic)? *

Yes No

Ever listed on a state or national abuse/neglect registry?

Yes No

Ever had a professional license revoked, suspended, or disciplined?

Yes No

Ever terminated for patient abuse, neglect, or exploitation?

Yes No

If YES to any above, please explain (attach sheet if needed):

I authorize Alfa Nursing Services, Inc. to conduct a Level 2 background check, verify all licenses, and contact references and former employers.

Applicant Signature

Date

8 Section 8 — HIV/AIDS Education Compliance

Required by ss.381.004, ss.384.25 & ss.400.506(8)(e) F.S.: HIV/AIDS education (minimum 3 contact hours) required prior to client placement.

I have completed a Board-approved HIV/AIDS education course (min. 3 hours) within the past 3 years. I have NOT completed the training. I understand I must do so before my first client placement.

Training Provider

Completion Date

Certificate # (if any)

9 Section 9 — Emergency Contact

Full Name *

Relationship *

Primary Phone *

Address

Alternate Phone

10 Section 10 — Authorization & Signature

I certify that all information is true and accurate. Misrepresentation is grounds for rejection or immediate termination. I authorize verification of all information and a Level 2 background check. I understand I am applying as an Independent Contractor and am responsible for my own taxes, licenses, and professional liability insurance. I agree to comply with HIPAA, ss.456.057 F.S., and all AHCA regulations applicable to Florida nurse registry contractors.

Applicant Signature

Date

Print Full Legal Name

For Office Use Only

Date Received

Screened By

Status

Background Cleared

Yes No

Independent Contractor Agreement — Florida Nurse Registry Services Agreement • ss.400.506(3)(a) F.S.

This Independent Contractor Agreement ("Agreement") is entered into between Alfa Nursing Services, Inc., a Florida licensed nurse registry (AHCA License #30211945), 1500 N.W. 89th Court, Suite 205, Doral, FL 33172 ("Registry"), and the undersigned healthcare professional ("Contractor").

1. Nature of Relationship

Contractor is an independent contractor and NOT an employee of the Registry. The Registry is licensed pursuant to ss.400.506 F.S. to refer healthcare professionals to clients. The Registry does not supervise, direct, or control the Contractor's professional performance. Contractor retains full professional autonomy and sole responsibility for care quality.

2. Services & Referrals

The Registry will refer Contractor to clients requiring home healthcare services. Contractor may accept or decline referrals. Accepted assignments shall be performed per the client's plan of care and applicable professional standards. Contractor shall notify the Registry promptly if unable to complete an accepted assignment.

3. Licensure, Certification & Compliance

Contractor warrants they hold all current, valid licenses and certifications required by law. Contractor agrees to: (a) maintain all licenses/certifications in good standing; (b) comply with HIPAA (45 CFR Parts 160 & 164) and ss.456.057 F.S.; (c) maintain current CPR/BLS certification; (d) complete HIV/AIDS education per ss.381.004 F.S.; (e) submit to and clear a Level 2 FDLE/FBI background screening per ss.400.512 F.S. and Chapter 435 F.S. prior to any placement; (f) comply with all AHCA regulations for nurse registry contractors.

4. Compensation & Taxes

Compensation shall be negotiated between Contractor and the client or as facilitated by the Registry. Contractor is solely responsible for all federal and state income taxes, self-employment taxes, and other contributions. Registry shall issue IRS Form 1099-NEC as required by law. Registry does not withhold taxes from Contractor payments.

5. Insurance

Contractor shall maintain, at their own expense: (a) Professional Liability Insurance — minimum $1,000,000/$3,000,000; (b) General Liability Insurance; (c) Auto Insurance if driving is required. Certificates of insurance shall be provided upon request. Registry does not provide workers' compensation for Contractor.

6. Confidentiality & HIPAA

Contractor shall maintain strict confidentiality of all client Protected Health Information (PHI) per HIPAA and ss.456.057 F.S. Contractor shall not disclose PHI to unauthorized parties and shall report any suspected breach to the Registry within 24 hours. This obligation survives termination of this Agreement.

7. Mandatory Reporting

Contractor is a mandatory reporter under Florida law. Contractor shall immediately report to the Florida Abuse Hotline (1-800-962-2873) and to the Registry any suspected or confirmed abuse, neglect, or exploitation of a vulnerable adult or child. Failure to report is a criminal violation under Florida law.

8. Non-Solicitation

Contractor shall not solicit, directly or indirectly, any client referred through the Registry for private employment during this Agreement and for twelve (12) months after termination, per ss.400.506 F.S.

9. Termination

Either party may terminate with 48 hours written notice. Registry may terminate immediately for: (a) failure to maintain licensure; (b) substantiated abuse, neglect, or exploitation; (c) HIPAA violations; (d) failure to clear background screening; or (e) criminal conviction.

10. Governing Law

This Agreement is governed by Florida law. Disputes shall be resolved in Miami-Dade County, Florida.

Contractor Signature

Date

Print Full Legal Name

SSN / EIN (Last 4 only)

For Alfa Nursing Services, Inc. — Authorized Representative

Date

Position Descriptions & Duties

Review the description for your applied position(s). Sign at the bottom to confirm receipt and understanding.

Home Health Aide (HHA)

Qualifications

Completed state-approved 40-hour HHA training program (Rule 59A-18.0081 F.A.C.)
Current CPR/BLS certification
Must pass Level 2 FDLE/FBI background screening (Chapter 435 F.S.)
Valid FL driver's license or reliable transportation

Essential Duties

Assist clients with ADLs: bathing, dressing, grooming, toileting
Light housekeeping and meal preparation
Assist with ambulation and transfers per plan of care
Medication reminders (NOT administration)
Monitor and report changes in client condition to supervising nurse
Complete EVV visit documentation accurately and on time
Maintain strict client confidentiality per HIPAA

Scope Limitations: May NOT administer medications, perform wound care, injections, catheter care, or IV therapy. All tasks must be within the approved plan of care and directed by the supervising nurse.

Certified Nursing Assistant (CNA)

Qualifications

Current FL CNA certification in good standing (FL CNA Registry)
Current CPR/BLS certification
Level 2 background screening clearance

Essential Duties

Assist clients with ADLs under RN/LPN supervision
Take and accurately record vital signs
Assist with range-of-motion exercises per care plan
Observe and report changes in patient status to supervising nurse
Complete EVV documentation accurately and timely

Scope Limitations: May NOT administer medications independently. May NOT perform IV therapy, wound care, or skilled nursing procedures. Must work under direct supervision of a licensed nurse.

Registered Nurse (RN)

Qualifications

Current, active FL RN license in good standing (FL Board of Nursing)
Current CPR/BLS certification
Level 2 background screening clearance
HIPAA compliance training current

Compliance

Maintain all licenses and CEUs per FL Board of Nursing
Adhere to AHCA Rule 59A-18 F.A.C. at all times
Report any changes in license status to Registry immediately

Essential Duties

Develop, review, and update client plans of care
Perform comprehensive skilled nursing assessments
Administer medications and treatments per physician orders
Wound care and IV therapy as ordered
Supervise and appropriately delegate to LPNs, CNAs, and HHAs per scope of practice
Document all findings in client medical record per AHCA requirements
Coordinate care with physicians, therapists, and client families

Licensed Practical Nurse (LPN)

Qualifications

Current FL LPN license in good standing
Current CPR/BLS certification
Level 2 background screening clearance

Scope Limitations

Must work under supervision of RN or physician. May NOT independently assess, plan, or evaluate nursing care without RN oversight.

Essential Duties

Administer medications per physician orders under RN supervision
Wound care per physician orders and plan of care
Monitor and promptly report changes in patient condition to supervising RN
Assist RN with complex procedures as directed
Document all services rendered per AHCA requirements

I have read, understand, and accept the position description and scope limitations for my applied position(s). I agree to perform only those duties within my licensure scope and the approved plan of care.

Contractor Signature

Date

Print Full Legal Name

Policies & Procedures Acknowledgment

Initial each item to confirm receipt and understanding.

Initial	Policy

Contractor Signature

Date

Print Name

Compliance Certifications & Health Requirements

A. HIPAA Compliance Certification

I certify that I have received HIPAA training and understand my obligations regarding Protected Health Information (PHI). I agree to: (1) access only PHI necessary for my duties; (2) report any unauthorized access, loss, or breach of PHI to the Registry within 24 hours; (3) use secure methods when transmitting any client information; (4) not use client information for personal use. I understand that violations carry civil penalties up to $1.9M per violation category and potential criminal prosecution.

Signature

Date

B. Confidentiality Agreement

I agree to hold all client information (medical, personal, financial) in strict confidence and to not disclose it to any unauthorized persons, including on social media, during or after my engagement with Alfa Nursing Services, Inc. This obligation is permanent and survives termination of the contractor relationship.

Signature

Date

C. Health Requirements & Medical Clearance

Required per AHCA Rule 59A-18 F.A.C.: All registry workers must demonstrate freedom from communicable disease and physical fitness prior to placement. Documentation must be on file before the first client assignment.

Requirement	Status	Documentation
TB Test / PPD Annual requirement	Negative Positive IGRA Blood Test	Results Attached
Influenza Vaccine Annual	Vaccinated Declined (Waiver req.)	Record Attached
Hepatitis B Vaccine	Vaccinated Titer+ Declined	Record Attached
COVID-19 Vaccination	Vaccinated Exemption on File	Record Attached
Physical Exam / Health Clearance Within prior 12 months	Completed	Form Attached
Drug Screening 10-panel urine screen	Negative Pending	Results Attached

If TB is POSITIVE: A chest X-ray within past 12 months and physician clearance confirming non-active TB status are required before any placement.

I certify that all health information is accurate and all required documentation will be provided before my first client assignment.

Signature

Date

Print Name

Orientation Checklist & Final Acknowledgments

Initial each topic reviewed. Sign all acknowledgment sections.

Part A — Orientation Topics Reviewed

Init.	Topic Covered

Part B — Additional Certifications

Social Media & HIPAA Acknowledgment

I understand that posting any client information, photo, video, or identifying details on any social media platform is a HIPAA violation, grounds for immediate termination, and may result in civil and criminal penalties.

Signature

Date

Equal Opportunity & Non-Discrimination

I will not discriminate against any client or colleague based on race, color, national origin, sex, age, disability, religion, or any other protected characteristic.

Signature

Date

Acknowledgment of Receipt of Package

I acknowledge receipt of: (1) Employment Application; (2) Independent Contractor Agreement; (3) Position Description; (4) Policies & Procedures; (5) HIPAA Notices; (6) Health Requirements; (7) This Orientation Checklist.

Signature

Date

Appendix A — Required Government Forms (To Be Attached Separately)

Download originals and attach to this package:

IRS Form W-9 (Taxpayer Identification) — irs.gov/forms-pubs/about-form-w-9
USCIS Form I-9 (Employment Eligibility) — uscis.gov/i-9
AHCA Form 3100-0008 (Background Screening Request) — ahca.myflorida.com
DOEA Form 236 (as applicable for CARES/Medicaid cases) — elderaffairs.state.fl.us
FDLE Livescan Request (Level 2 Fingerprinting) — fdle.state.fl.us

By submitting this application you certify all information is true and accurate, and that you have read, understood, and agree to all policies above.

School / Program	Location	Degree / Course of Study	From	To	Completed?
					Y N
					Y N
					Y N

Employment Application & Compliance Package

Employer #1 (Most Recent)

Employer #2

Employer #3

Reference #1

Reference #2

Reference #3

For Office Use Only

Home Health Aide (HHA)

Certified Nursing Assistant (CNA)

Registered Nurse (RN)

Licensed Practical Nurse (LPN)