VitaCare Employee Application
Date
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Month
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Day
Year
Date
Personal Information
What is your Name?
First Name
Last 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.
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What is your date of birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
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2003
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1935
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
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?
English
Spanish
Russian
French
Other
Who is your emergency contact
First Name
Last 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?
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License & Certificate
Do you have a drivers license?
Yes
No
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?
-
Month
-
Day
Year
Date
What is the expiration date given for your CHHA license?
-
Month
-
Day
Year
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
Yes
No
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Education
What is your highest level of education
GED
Highschool
College
Other
In what year did you compelete this education
Where did you complete you {whatIs93} education
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Medical Screening & Clearance
What was the date of your last physical exam?
-
Month
-
Day
Year
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
Yes
No
Have you ever been convicted of a felony or misdemeanor crime?
Yes
No
(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
Yes
No
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Work Availability
What is your means of transportation to get to and from work?
My own vehicle
Public Transportation
Reliant on Friends or Family
Uber/taxi
Other
What is your desired pay range?
Please put how much you desire to make per hour/day.
What type of work are you able to do
Hourly
Live-in
What days are you interested in working
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What shifts are you interested in working
Mornings
Afternoons
Evenings
Overnight
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Work History & References
What company is your most recent employer
*
Name of supervisor
*
First Name
Last 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.
Yes
No
Please provide the company name of an additional past employer
What was the name of your supervisor
First Name
Last Name
What is the phone number of this company
Format: (000) 000-0000.
Please provide the name of a personal refrence
First Name
Last Name
What is their phone number
Format: (000) 000-0000.
Please provide the name of a second personal refrence
First Name
Last Name
What is their phone number
Format: (000) 000-0000.
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Banking Information
Do you wish to receive direct deposit?
Yes
No
What is the name of your bank?
Account Type
Checking
Savings
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?
Yes
No
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Skill Assessment
Please indicated your experience levels with patient needs and skill sets
Rows
Experienced
Some Experience
No Experience
Dementia
Parkinson
Hospice
Stroke
Head Trauma
Diabetes
Blood sugar test
sliding scale
Heart issues
Housekeeping
Grooming
Bathing
Oral Care
Toileting
Meal prep
Cooking
Feeding
Feeding Tube
Transferring
Hoyer Lift
Slide Board
Range of motion
Gait Belt
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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
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