Application

Application

Please complete the form below in its entirety
Full Name*

First NameMiddle NameLast Name
Preferred Name*
Date of Birth*
Social Security Number*
Driver's License Number*
YesNo
Copy of Proof of Car Insurance*

Browse Files

Cancelof
Copy of Driver's License*

Browse Files

Cancelof
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Facebook Name*
Instagram Username*
Referred by:*
If referred by someone, please list who. If not put N/A.*
Emergency Contact #1*
Name
Relation*
Phone Number*

Area CodePhone Number
Emergency Contact #2*
Name
Relation*
Phone Number*

Area CodePhone Number
Work History

Please list work history from the past 5 years. Include the date of employment, position held, reason for leaving, and a phone number of the previous employer. If there is a break in employment, please leave reason below. (i.e. stay at home mom, retired, looking for another job, etc.)
Work History #1*
Work History #2
Work History #3
Work History #4
Work History #5
Have a gap in employment between jobs? Please explain here:
Personal References

Please list at least 3 personal references. (These references must have known you for at least 5 years). DO NOT list family members or duplicate work reference contacts.
Please include the name and phone number of each reference, as well as the years known.
Personal Reference #1*
Personal Reference #2*
Personal Reference #3*
Personal Reference #4
Personal Reference #5
Have you ever been charged with a criminal offense? If so please give a brief explanation.*
All of the above information is true to the best of my knowledge. I hereby authorize Prestige Homecare, LLC to request and recieve any information and records including, but not limited to, criminal background check, driving, and previous/present employment, from any corporations, individuals, association, agencies or departments.
Date*

MonthDayYear
Date
Signature*
By signing, I agree that I have read and agree to the Terms & Conditions*
Once the application is submitted, you will be redirected to a new page letting you know the application has been sent in. If you do not see this message, your application has not been sent in.

Please make sure all required fields above are completed correctly or the application will not come through correctly.
Should be Empty:

Application

Work History

Personal References

Once the application is submitted, you will be redirected to a new page letting you know the application has been sent in. If you do not see this message, your application has not been sent in.