A Prime-Time Home Care Agency
Job Application
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Social Security Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What position are you applying for?
*
Caregiver
HHA
CNA
Transportation
Other
Have you ever been charged with a felony or misdemeanor? If hired, you will be required to do a background check.
*
Yes
No
If yes, Please explain
Please select all that apply to you.
*
CPR Certified
Copy of recent TB
Valid Drivers License
Car Insurance
CNA Certification
HHA Certification
Covid- 19 Vaccination
Please Upload a copy of Drivers License or ID
*
Browse Files
Drag and drop files here
Choose a file
A Copy is required before your start date
Cancel
of
Please upload a copy of your social security card
Browse Files
Drag and drop files here
Choose a file
A copy is required before your start date
Cancel
of
Please upload CPR and TB Shot documents
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please upload any other relevant documents
Browse Files
Drag and drop files here
Choose a file
Cancel
of
What specific shift/hours are you looking to work?
*
How many hours do you want to work a week?
*
How much do you want to make an hour?
*
Are you willing to travel? How far?
*
Are you willing to work weekends?
*
Every
Rotating
NONE
I am comfortable (select all that apply)
*
being around dogs
being around cats
being around pets
being around cigarette smoke
with showering/bathing clients
with hoyer lifts
with transferring clients i.e bed to chair
Do you have a valid driver's license?
*
Yes
No
Do you have a car? (may need to run errands for clients or transport clients)
*
Yes
No
Please list any other relevant information
Please list 1 (one) professional reference- Name, Phone Number, Brief description of relationship.
*
Please list 1 (one) personal reference- Name, Phone Number, Brief description of relationship
*
If you are coming with a client please list client name and relationship to you. i.e. Jane Doe- MOTHER
If you were referred by an employee or client, please list their name below
Are you currently taking care of a family member?
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