Application

Application

Please complete the form below
Full Name *

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

Yes No
Please send a copy of your driver's license to Hope Langley at (256)605-5055. Thank you!
Copy of Proof of Car Insurance

Browse Files

Cancel of
Current Address *

Street Address

Street Address Line 2

City State / Province

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

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

Area Code Phone 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 *

Month Day Year
Date
Signature *
By signing, I agree that I have read and agree to the Terms & Conditions *
Should be Empty:

Application

Work History

Personal References