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Dear Applicant:

Thank you for your interest in employment with A Caring Heart Case Management, Inc. Please complete this application and submit it. We will review your responses and contact you for an interview if we determine you to be a likely candidate for the position.

Please note that if you are contacted for an interview, copies of the following documents will be required at the time of the interview. Please bring these items with you to the interview:
- Driver’s license
- Social Security Card
- Evidence of highest education level completed - High school diploma, GED, or college diploma (or official college transcripts)
- Current car registration
- Current proof of car insurance (declaration page)
A Caring Heart Case Management, Inc., is an equal opportunity employer, dedicated to a policy of non- discrimination in employment on any basis including age, sex, color, race, creed, national origin, religion, marital status, sexual orientation, political belief, or disability.

Federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization and identity within three (3) days of being hired. Failure to submit such proof within the required time shall result in immediate employment termination.
Please choose one: I am applying as an*

EmployeeRelative as Provider (RAP) Contractor
Preferred Office Location: Please choose one.*

ClintonGoldsboroGreenvilleJacksonvilleKenansvilleRocky MountSmithfieldWilmingtonWilson
EMPLOYMENT/RAP CONTRACTOR APPLICATION

PERSONAL DATA
Today's Date*

MonthDayYear
Date
First Name*
Middle/Maiden
Last Name*
Address*

Street Address

Street Address Line 2

CityState

Zip
In what NC county do you reside?*
Home Telephone Number

Area CodePhone Number
Cellular Telephone Number*

Area CodePhone Number
Email*
Are you 18 years of age or older?*

YesNo
Have you ever been convicted of a crime?*

YesNo
If yes, please explain: (THE EXISTENCE OF A CRIMINAL RECORD DOES NOT AUTOMATICLLY DISQUALIFY YOU FROM EMPLOYMENT.) Length of time since last conviction(s) and seriousness of conviction(s) are considered.
Position Desired/Availability
Position Desired*
If "Other" chosen, please specify position:
Position*

Full TimePart Time
When are you available to work? Please provide days and hours available to work. (Shift hours vary per consumer choice. These are approximate times per shift:
- 1st Shift: 7 a.m. - 3 p.m
- 2nd Shift: 3 p.m. - 11 p.m
- 3rd Shift: 11 p.m - 7 a.m

	1st Shift	2nd Shift	3rd Shift	Not Available
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Number of hours available per week*
Please provide additional information about availability. For example, if you are available first shift but only from 9 a.m. - 12:30 p.m.
How far are you willing to travel (for this position) from your residence to a consumer’s residence or to an A Caring Heart facility? *
Miles
What date could you start work?*

MonthDayYear
Date
Pay Rate Desired
Hourly/Salary (Please specify hourly rate or annual salary)*
Education
High School:*

Name of School

City/State

Date GraduatedType of Diploma (HS Diploma or GED)

Postal / Zip Code
College/University:

Name of College/University

City/State

Date GraduatedMajor

Degree
College/University:

Name of College/University

City/State

Date GraduatedMajor

Degree
Training/Certificates
Please indicate any certificates earned or in progress, and/or any training programs not included in your formal education. List any CNA, LPN, RN or other professional license, license number, and date of expiration. List CPR/FA, NCI, CPI, Safety Care certifications.*
Employment History
List your current or most recent employment first. Include work-related internships, military, and volunteer work. Reference checks are required to be considered for hire. Please provide contact information to a specfic person or department. If possible, please avoid putting general employer phone numbers. A direct contact number is ideal.
Current/Most Recent Employer:*
Please choose one:*

Current EmployerMost Recent Employer
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor /Job Title:*
Supervisor's Phone Number*

Area CodePhone Number
Your Position*
Rate of Pay (Salary or Hourly)*
Dates of Employment:
From*

MonthDayYear
Date
To*

MonthDayYear
Date
May we contact?*

YesNo
Complete and sufficient reference checks are required by the State of NC. Answering "no" to this question may delay the application process.
My employment history is limited to the one job listed above.*

YesNo (Please add additional employers below)
Previous Employer*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor/Job Title*
Supervisor Phone Number*

Area CodePhone Number
Your Position*
Rate of Pay (Salary or Hourly)*
Dates of Employment:
From:*

MonthDayYear
Date
To:*

MonthDayYear
Date
May we contact?*

YesNo
Complete and sufficient reference checks are required by the State of NC. Answering "no" to this question may delay the application process.
Previous Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor/ Job Title
Supervisor Phone Number

Area CodePhone Number
Your Position
Rate of Pay (Salary or Hourly)
Dates of Employment:
From:

MonthDayYear
Date
To:

MonthDayYear
Date
May we contact?

YesNo
Complete and sufficient reference checks are required by the State of NC. Answering "no" to this question may delay the application process.
If not listed above, what experience do you have working with individuals with intellectual and/or developmental disabilities?
Referral Source
How were you referred to A Caring Heart Case Management, Inc.?*

Employment AgencyNC Employment Security CommissionIndeedAdvertisementACHCM WebsiteACHCM Facebook PageACHCM EmployeeFlyer/PosterOther
If referred by an ACHCM employee, please provide employee's name:
Additional Comments/Information
ACKNOWLEDGEMENT OF AT WILL EMPLOYMENT/RELEASE OF LIABILITY

All hiring and employment at A Caring Heart Case Management, Inc. is at will. I understand this application is not an employment contract, nor can it be used to create one. Employment or contracted work as a Relative as Provider (RAP) by A Caring Heart Case Management, Inc., has no specific term and may be terminated by the employee/RAP contractor or A Caring Heart Case Management, Inc., with or without notice. I acknowledge that A Caring Heart Case Management, Inc., has not made any promises or representations that differ from those contained in this paragraph.

I understand I must provide a copy of my high school diploma, a current driver’s license, and other pertinent documentation, if I am offered a position with A Caring Heart Case Management, Inc., and that failure to provide this evidence will result in the termination of my employment.

I understand I must provide satisfactory documents to establish my identity and right to work in the United States if I am offered a position with A Caring Heart Case Management, Inc., and that failure to provide this evidence will result in the termination of my employment.

I hereby authorize without reservation, any party or agency contacted by this employer to furnish the above-mentioned information.

I release and agree to hold harmless any individual, company, business institution or government agency from all liability with regard to furnishing information to A Caring Heart Case Management, Inc. I agree to release and hold harmless A Caring Heart Case Management, Inc., from all liability with respect to the receipt of such information.

DRUG/ALCOHOL SCREENING CONSENT

If I become an employee/RAP contractor of A Caring Heart Case Management, Inc., I agree to submit to drug and/or alcohol testing in any situation where reasonable cause for suspicion exists or when an accident occurs, and drugs or alcohol could be a contributing factor.

CERTIFICATION OF INFORMATION PROVIDED IN THIS APPLICATION

I certify that the information I have furnished on this application form is true and complete. I understand that if any misrepresentation has been made by me verbally or in writing, any offer of employment made to me may be withdrawn or my subsequent employment with A Caring Heart Case Management, Inc., may be terminated.
Applicant Electronic Signature Agreement
My electronic typed signature below is verification of my agreement with the above statements. I understand and agree that my typed name below is equivalent to my handwritten signature on this employment application.*

I agree with the terms of this agreement.
Electronic Signature: Type Full Name:*

First NameLast Name
Date of Electronic Signature*

MonthDayYear
Date
Please upload in PDF or Word format:

1. Vehicle registration card

2. Vehicle insurance declaration page. (We need the declaration page, not the insurance card. The declaration page summarizes your policy and coverages, limits and deductibles, and the effective dates of your policy.)

3. Evidence of highest education level completed: High school diploma, GED, or college diploma (or official college transcripts)

4. Resume: This is optional unless we requested it.
Upload Documents

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Thank you for your interest in employment with A Caring Heart Case Management, Inc. Please direct questions to:

Zak Mitchell

Human Resources Director

Home Office: 180 Coastal Lane, Jacksonville, NC 28546

Phone: (910) 340-0769 (mobile)

Email: zmitchell@acaringheartinc.com

Visit our website at acaringheartinc.com and check us out on Facebook (A Caring Heart Case Management).
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