VitaCare Employee Application

VitaCare Employee Application
Date

MonthDayYear
Date
Personal Information
What is your Name?

First NameLast Name
What is your Email
example@example.com
What is your phone number
Format: (000) 000-0000.
Please upload a picture of your self

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This will be used for your employee badge, Please Smile. Cancelof
What is your date of birth

MonthDayYear
What is your Social Security number
Please upload a picture of your Social Security Card

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What is your full home address
What language can you speak?

Other
Who is your emergency contact

First NameLast Name
What is your relationship with {whoIs}
What is {whoIs} phone number?
Format: (000) 000-0000.
How many total years of caregiving experience do you have as an CHHA?

License & Certificate
Do you have a drivers license?
What is your drivers license number
Please upload your Photo ID and/or Driver License

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What is your CHHA License number?
What is the intial date given for your CHHA license?

MonthDayYear
Date
What is the expiration date given for your CHHA license?

MonthDayYear
Date
Please upload a picture of your CHHA license

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Do you confirm you CHHA license is up to date and in good standing with the NJ Board of nursing

Medical Screening & Clearance
What was the date of your last physical exam?

MonthDayYear
Date
Please upload a picture of your physical exam/medical clearance to work

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Please upload a picture of your TB screening

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Please upload a picture of your Rubella screening

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Legal
Are you legally authorized to work in the USA
Have you ever been convicted of a felony or misdemeanor crime?
(This does not apply if the conviction has been expunged, is contained in a sealed record, or was a juvenile conviction.) A criminal conviction will not necessarily bar you from employment. We will consider the nature of the crime, the time that has expired since its occurrence and any rehabilitation you have undergone.
Do you consent and allow VitaCare Support LLC to use your information to run a background check

Work History & References
What company is your most recent employer
Name of supervisor

First NameLast Name
Dates your worked at {whatCompany}
Address for {whatCompany}
Phone Number for {whatCompany}
Format: (000) 000-0000.
Reasons for leaving
Do you hereby authorize VitaCare Support LLC to request and receive from all prior employers within one (1) year of the date of this application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination.
Please provide the company name of an additional past employer
What was the name of your supervisor

First NameLast Name
What is the phone number of this company
Format: (000) 000-0000.
Please provide the name of a personal refrence

First NameLast Name
What is their phone number
Format: (000) 000-0000.
Please provide the name of a second personal refrence

First NameLast Name
What is their phone number
Format: (000) 000-0000.

Banking Information
Do you wish to receive direct deposit?
What is the name of your bank?
Account Type
Bank Routing Number
Bank Account Number
Do you hereby authorize VitaCare Support LLC to use this information to set up your direct deposit and electronically transfer funds to your account?

Acknowledgement & Legal
Please provide your signature in acknowledgement that agrees to all of the information you've submitted in this application. You are also agreeing to all release all information included in this employee application to VitaCare Support LLC
Should be Empty:

Personal Information