Application

Application

Please complete the form below
Full Name*

First NameMiddle NameLast Name
Preferred Name*
Date of Birth*
Social Security Number*
Driver's License Number*
Have you been vaccinated for COVID-19?*

YesNo
Please send a copy of your driver's license to Shelby Smith at (256)605-6029. Thank you!
Copy of Proof of Car Insurance

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 all work history. Include the date of employment, position held, reason for leaving, and a phone number of the previous employer.
Work History #1*
Work History #2
Work History #3
Work History #4
Work History #5
Personal References

Please list at least 3 personal references. (One 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*
Should be Empty:

Application

Work History

Personal References