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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.
I am applying as an*

Independent AFL Contractor
Preferred Office Location: Please choose one.*

ClintonGoldsboroGreenvilleJacksonvilleKenansvilleRocky MountSmithfieldWilmingtonWilson
AFL INDEPENDENT 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*
Information Needed for Identification, Statistical Purposes, and Background Checks
Other former names (maiden etc.) (Type N/A if none)*
Social Security Number*
Driver's License State*
Driver's License Number*
Date of Birth*

MonthDayYear
Date
Race*
If other please specify
Ethnicity*
If other please specify
Gender*
Have you lived in any state other than NC during the past five years?

YesNo
If YES, please list all states and dates of residency below:
State
Dates of residency (Beginning Year - End Year)
State
Dates of residency (Beginning Year - End Year)
State
Dates of residency (Beginning Year - End Year)
Are you 18 years of age or older?*

YesNo
Are you 18 years of age or older?*

YesNo
Have you ever been convicted of a crime?*

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.
Are you currently under active investigation and/or have substantiated allegations of abuse, neglect, or exploitation by a government agency in the past 10 years?*

YesNo
If yes, please explain. If there have been questionable instances please explain.
Position Desired/Availability
Position Desired: AFL (Alternative Family Living) Provider (This application form is for contracted AFL providers only)
Duty Hours: 24 hours a day, 7 days per week providing comprehensive services which provide training, supports, and supervision to the consumer with intellectual/developmental disabilities within a private home setting and in the community. The AFL provider has 24 hours/7 days a week responsibility for the consumer served and is responsible for supervision, monitoring and support of the consumer when the consumer is not engaged in other services.

It is the responsibility of the AFL provider to care for the consumer if the consumer is sick or is suspended from a day program due to his/her behavior. If AFL provider is contacted and informed that the consumer is not feeling well or that the consumer’s behavior is not acceptable, it is the AFL provider’s responsibility to come and get the consumer in a timely manner.

A Caring Heart’s AFL providers often provide day program services to other consumers while their AFL consumer is attending a day program or school. AFL providers are permitted to provide services to other consumers but their primary responsibility is to their AFL consumer. Please use a separate employment application (Employee/RAP application form when applying for additional positions with A Caring Heart.)
Are you available to provide AFL services 24 hours per day/7 days per week?*

YesNo
Are you available to provide AFL services 24 hours per day/7 days per week?*

YesNo
What date could you start work?*

MonthDayYear
Date
Pay Rate Desired
Please specify daily rate (AFL providers are paid per diem)*
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.
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 EmployeeOther
If referred by an ACHCM employee, please provide employee's name:
Additional Comments/Information
PERMISSION TO PERFORM INVESTIGATIVE BACKGROUND INQUIRIES

In connection with my application for employment or as a RAP/AFL contractor and as a condition of continuing employment, I understand that investigative background inquiries may be made on me including previous employers, schools, criminal convictions, motor vehicle, and other reports. These reports will include information as to my character, work habits, performance, education, compensation, and experience along with reasons for termination of employment from previous employers. Furthermore, I understand that the company may request information from various federal, state, and other agencies which maintain records concerning my past activities related to driving, criminal, or civil records. I authorize, without reservation, any party or agency contacted to furnish the abovementioned information and release all parties involved from liability and responsibility for doing so. I hereby consent to obtaining the above information by A Caring Heart Case Management, Inc. and/or any of its agents. This authorization and consent shall be valid in original, fax, or copy form.

CONFIDENTIALITY STATEMENT

I understand that any information obtained during the interview process or as an employee or RAP/AFL contractor working with clients of A Caring Heart Case Management, Inc., is strictly confidential. I agree never to discuss any client information with anyone not directly involved with the client. Whether or not I become an employee or RAP/AFL contractor of A Caring Heart Case Management, Inc., I will not disclose any confidential information to any other agency or person before, during, or after my employment with the company. I further understand that if A Caring Heart Case Management, Inc. does employ/contract me, any disclosure of confidential material will result in my immediate dismissal from A Caring Heart Case Management, Inc.

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
Electronic Signature Date:*

MonthDayYear
Date
Please upload in PDF or Word format.

1. Vehicle Registration Card

2. Vehicle Insurance Declaration Page. (The declaration page summarizes your policy and coverages, limits and deductibles, and the dates your policy is effective.)

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 contracting work with A Caring Heart Case Management, Inc. as an AFL provider. Please direct questions to:

Erin Mairs

AFL Marketing and Development Specialist

Home Office: 4005 Oleander Drive, Wilmington, NC 28403

Phone: 910-523-2520 (mobile)

Email: emairs@acaringheartinc.com

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