ECH EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION

🔒 Privacy Policy & Data Use Statement for Employment Applicants

At Eminent Caring Hands Home Care (ECH), we are committed to protecting your privacy and the personal information you provide to us during the application process. The data you submit through this application form is collected solely for employment-related purposes and will be handled with the highest level of confidentiality and care.

What We Collect and Why:
We collect the following types of information and their intended use is outlined below:

Full Legal Name & Contact Information: To identify you and communicate about your application
Date of Birth: To verify eligibility for employment
Social Security Number (SSN): Required for background checks and payroll setup (if hired)
Driver’s License / State ID: For positions that may require travel or client transport verification
Address History & Residency: For background screening and employment records
Employment & Education History: To assess your qualifications and experience
Professional Certifications (e.g., CNA, PCA): To validate credentials for caregiving roles
Emergency Contact Info: To keep on file if needed during employment
References: For employment verification and character review

All information is used strictly for hiring, onboarding, and regulatory compliance related to your potential employment with ECH.

Data Storage & Protection:
Your information is stored securely through JotForm’s encrypted servers and only accessible to authorized personnel.
Sensitive information, such as your SSN, will never be shared or sold and is only used for required background checks and employment verification.

We retain your data only as long as necessary for the hiring process or to comply with legal and regulatory requirements.

Consent:
By submitting this application, you confirm that all information provided is accurate to the best of your knowledge. You also consent to the collection, secure handling, and use of your personal data as described in this privacy policy.

I have read and agree to the terms outlined in this Privacy Policy & Data Use Statement. (Required to submit application).*

I CONSENT I HAVE READ AND UNDERSTAND THE PRIVACY POLICY AND DATA USE STATEMENT.

Name *

First NameMiddle NameLast Name

Date of Birth *

MonthDayYear

Social Security Number *

9 digit# XXXXXXXXX

Drivers License Number *

8 digit #

DL State Issued*

DL Date of Expiration *

Date

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number:*

E-mail Address:*

example@example.com

Position Applying for*

PCA, CNA, RN, OFFICE STAFF, OTHER

Availability *

	1st shift	2nd shift	3rd shift	Weekend only shift	Overnighter shift	PRN	Not Available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

List specific times here for availability

Use this space to to include when you aren’t available and specific times...

Have you lived in any other state within the last 5 years?*

YesNo

If yes to the above question; please provide name of States you have resided?*

List all States outside of NC

To be eligible for hire with ECH you must consent to a Criminal Background Investigation and will be require to sign a SBI Authorization form to be submitted for review. Are you willing to sign this form and have the Criminal Background Investigation performed?

𝐒𝐓𝐀𝐓𝐄𝐌𝐄𝐍𝐓:Eminent Caring Hands Home Care adheres to strict hiring policies in North Carolina and cannot employ individuals with certain criminal charges or convictions, including violent crimes, sexual offenses, fraud, and drug-related charges, as per NCDHHS regulations. This ensures the safety and well-being of our clients.

Have you ever been charged/convicted of a misdemeanor or felony in any state? If so please list the charge/conviction, provide County, City&State of charge/conviction; date of charge/ conviction; and description (if you desire to explain.)*

Please list any Environmental conditions you do not prefer to work with for In Home caregivers position...

Example: Caregiver is adverse to working with dogs but cats are okay, I don’t mind working with smokers....

How were you referred to us?*

Other:

Upload Resume:

Work Experience

Company Name*

Address*

Name of Last Supervisor *

Phone *

Start date *

Start salary*

End date*

Ending salary*

Last job title*

Reason for leaving(be specific) *

May we contact this employer?*

Dropdown arrow to select

Job Skills & Training

Describe your skills:*

Training or Certifications:*

Have you ever been reported to any registry/licensure/certification board for misconduct in NC or any other state?*

References

Please list two (2) references that are familiar with your work life.

Reference 1

Name:*

First NameLast Name

Phone Number*

What is your relationship to this reference?*

PersonalProfessional

Years Known:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Reference 2

Name:*

First NameLast Name

Phone Number*

What is your relationship to this reference?*

PersonalProfessional

Years Known:*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supplemental Questions

Please Answer completely. Application will be considered incomplete if left blank.

1. Do you have any professional caregiver experience?*

2. Are you COMPASSIONATE ? Explain how you show this characteristic.*

3. Are you EMPATHETIC to others? Explain how you show this characteristic.*

Please explain in your own words what it means to you to operate with INTEGRITY.*

*Please DO NOT leave any question unresponded. If the question doesn't apply to you fill in with (N/A).

Signature*