Apex VIP Care: Caregiver/ Staff Application Form
We are an Equal Opportunity Employer and committed to excellence through diversity.
Personal Information
Name
*
First Name
Last Name
Phone Number
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is the best time to contact you?
*
Please Select
Morning
Lunch Time
Evening
Afternoon
Doesn't Matter
Are you currently legally entitled to work in the country where the job is based?
*
Yes
No
If applicable, please detail any restrictions:
*
Do You Have a Valid and Unrestricted Drivers License?
Yes
No
Do you have reliable transporation?
*
Yes
No
Have you ever been charged with a crime other than a traffic ticket?
*
Yes
No
If you have been charged with a crime other than a traffic ticket, please explain:
If selected for employment do you understand that you will need to submit a background check?
*
Yes
No
If hired, do you understand that you may be required to submit a drug test?
*
Yes
No
If hired, do you understand that you must have a tuberculosis skin test or chest x-ray completed?
*
Yes
No
Is there any reason that you cannot be tested for tuberculosis?
*
Do you speak and understand the English Language?
*
Yes
No
Languages spoken other than English:
Position Information
What position are you applying for?
*
Please Select
Companion Care
Homemaker
Personal Care Aide
Bath Aide Only
Licensed Professional Nurse
Registered Professional Nurse
Other Administrative Role
What is your desired employment?
Full Time (40 HOours weekly)
Part Time
Per Diem (As Needed)
Georgia Counties You Are Availble to Accept Assignements In (Select all that apply):
Butts County
Clayton County
Cowetta County
Dekalb County
Douglas County
Fayette County
Fulton County
Henry County
Rockdale County
Spalding County
What is your desired hourly pay?
*
Hourly
What is your available start date?
*
-
Month
-
Day
Year
Date
Time of Day that you prefer to work:
*
Morning
Afternoon
Evenings
Nights
Are you availble to work Weekends and / or Holidays?
*
Yes
No
What certification or professional license do you hold? CNA/ PCA/ HHA/ LPN/ RN: copies must be presented if selected for employement
*
Additional certification or professional license held:
Education
Work Experience
Please include up to past 5 years
Manager/ Supervisor Name
*
Manager/ Supervisor Phone or Email:
*
Previous Job Description/ Duties:
*
Reason for leaving:
*
Manager/ Supervisor Name
*
Manager/ Supervisor Phone or Email:
*
Previous Job Description/ Duties:
*
Reason for leaving:
*
Manager/ Supervisor Name
*
Manager/ Supervisor Phone or Email:
*
Previous Job Description/ Duties:
*
Reason for leaving:
*
Manager/ Supervisor Name
*
Manager/ Supervisor Phone or Email:
*
Previous Job Description/ Duties:
*
Reason for leaving:
*
Manager/ Supervisor Name
*
Manager/ Supervisor Phone or Email:
*
Previous Job Description/ Duties:
*
Reason for leaving:
*
Manager/ Supervisor Name
*
Manager/ Supervisor Phone or Email:
*
Previous Job Description/ Duties:
*
Reason for leaving:
*
Qualifications
Microsoft Office
1
2
3
4
5
Communication Skills
1
2
3
4
5
SEO
1
2
3
4
5
References
Type a question
Upload License/ Certification- CNA/ PCA/ LPN/ RN- Must present in person if hired
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Upload CPR, BLS and First Aid Certifications- Must present in person if hired
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Choose a file
Cancel
of
Upload TB Test (Must be within 1 year) - Must present in person if hired
Browse Files
Drag and drop files here
Choose a file
Cancel
of
By submitting this application, you agree that the information submitted is correct to the best of my knowledge.
Agreed
Date
*
-
Month
-
Day
Year
Date
Signature
*
Please verify that you are human
*
Submit
Submit
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