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  • Employment Application

    North Carolina Personal Care Services, LLC is an equal opportunity employer. Applicants are considered for employment without regard to race, color, national origin, religion, sex, gender, age, marital status, veteran status, disability, or any other status protected by applicable law.

    Applicants requiring a reasonable accommodation to complete the application or participate in the interview process should contact our Human Resources Representative.

    Application Instructions:
    Please answer each question completely and accurately. Incomplete applications may not be considered. If an offer of employment is made, employment eligibility and other applicable employment requirements will be verified.

  • Date of Birth *
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Position(s) applying for*
  • Are you able to perform the essential functions and physical requirements of the position for which you are applying, with or without reasonable accommodation?
  • Are you over the age of 18?*
  • Are you eligible to work in the United States?*
  • Are you fluent in a foreign language?*
  • Are you currently employed?*
  • Date available for work*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you available to work?*
  • What days are you available to work?*
  • Earliest time available for work?*
  • Latest time available for work?*
  • Have you applied here before?*
  • Have you been convicted of a felony/misdemeanor (other than traffic violations)?*
  • EDUCATION
  • Please complete the appropriate sections*
    Rows

  • LICENSE/CERTIFICATIONS

  • Professional License
    Rows
  • Current Certifications (check applicable certifications):
  • WORK HISTORY Please list your four most recent employers, list the most recent first
  • 1. Employer
  • May we contact this employer?*
  • Format: (000) 000-0000.
  • 2. Employer
  • May we contact this employer?
  • Format: (000) 000-0000.
  • 3. Employer
  • May we contact this employer?
  •  -
  • 4. Employer
  • May we contact this employer?
  • Format: (000) 000-0000.
  • Previous Facility Types Worked (Check all that apply)
  • ADDITIONAL INFORMATION 
  • Do you have a U.S. military service record?*
  • REFERENCES List three professional references, (business or work, not relatives) that you have known for at least one year. *
    Rows

  • ADDITIONAL INFORMATION 

  • AUTHORIZATION I understand that North Carolina Personal Care Services LLC is making no employment offer at this time. I certify that the information in this application is correct to the best of my knowledge. I understand that any misrepresentation or omission of any fact in my application, resume, or any other materials, or during interviews is grounds for disqualification from further consideration for employment or for termination, if employed. I authorize North Carolina Personal Care Services LLC to contact any company, institution, or individual it deems appropriate to investigate my employment history, character, qualifications, credit history, driving record, and other relevant information, if job-related. I give my full consent for all contacted individuals, including former employers, to provide information concerning this application, and I waive my right to bring any cause of action against these individuals for any and all liability for damages arising from furnishing the requested information to North Carolina Personal Care Services LLC. I acknowledge that a facsimile and/or photocopy of this form is as valid as the original. Pre-employment testing may be required (drug testing, background checks, physical examinations, motor vehicle checks). I understand that any offer of employment may be withdrawn if drug tests are positive and/or if a condition is discovered for which no reasonable accommodation can be made. I understand that this application is current for 60 days. At the conclusion of this time, if I have not heard from North Carolina Personal Care Services LLC and still wish to be considered for employment, it will be necessary to complete a new application. I understand that if hired, employment is at-will, regardless of the employer, and may be terminated by myself, the employer or North Carolina Personal Care Services LLC at any time, with or without cause or notice, for any reason or no reason.

  • By entering your name, you agree to accept the terms of the above document with an electronic signature.*
  • You must agree to accept the terms of the document in order to submit an application. 
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
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