Job Application

GRAND STRAND HOME CARE

JOB APPLICATION for PERSONAL CARE AIDE
INTRODUCTION
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Social Security Number
Gender*

MaleFemaleNon-Bianary
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
EDUCATION

Please write the name of the degree earned
High School
College or higher
Select all the certification that you have (not required)

CPRBasic Life SupportFood SafetyDementia Care
AVAILABILITY FOR WORK
Select your availability (select all that apply)

Full-TimePart-TimeSplit-ShiftShort Notice (Fill-In)
Days available to work

SundayMondayTuesdayWednesdayThursdayFridaySaturday
WORK DUTIES
Select all duties you HAVE experience with

Bathing/ ShoweringGroomingOral CareDressingBowel CareBladder CareAdult DiapersFeedingHousekeepingLaundryMeal PreperationTransportationMedication ReminderTurning in BedUsing LiftMoving from Bed to Wheelchair
Select all duties you are NOT willing to do

Bathing/ ShoweringGroomingOral CareDressingBowel CareBladder CareAdult DiapersFeedingHousekeepingLaundryMeal PreperationTransportationMedication ReminderTurning in BedUsing LiftMoving from Bed to Wheelchair
TRANSPORTATION
Do you have a valid Driver’s License?
Do you have your own personal vehicle that will be available during your work hours?
Are you willing to transport clients in your vehicle?
REFERENCES

Work Reference #1
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Company Name
Position
Work Relationship
Work Reference #2
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Company Name
Position
Work Relationship
Personal Reference
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained in this application, as required. Also, I authorize the employer to contact any or all references to gather information regarding my work or personal ethics. I discharge any of the above and Grand Strand Home Care of any and all liabilities.

I understand that, if I am hired, I may be required to provide proof of citizenship of the United States of America or proof that I am currently authorized to work in the United States
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

GRAND STRAND HOME CARE

INTRODUCTION

EDUCATION

AVAILABILITY FOR WORK

WORK DUTIES

TRANSPORTATION

REFERENCES