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
*
Format: (000) 000-0000.
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?
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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?
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Yes
No
If hired, do you understand that you must have a tuberculosis skin test or chest x-ray completed?
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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?
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Hourly
What is your available start date?
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-
Month
-
Day
Year
Date
Time of Day that you prefer to work:
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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
Optional: Upload License/ Certification- CNA/ PCA/ LPN/ RN- Must present in person if hired
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Optional: Upload CPR, BLS and First Aid Certifications- Must present in person if hired
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Optional: 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
ACKNOWLEDGEMENT & CONSENT (required) (please read carefully and sign below) I certify that the information in this application is accurate, current and complete. I understand that misstatements or omissions may result in disqualification from further consideration or termination of employment. I agree that, if hired, I may be discharged from employment if Apex VIP Care, LLC learns of any falsification or material omission in the information I have provided and if discovered prior to hire, I would be ineligible for consideration if you have been convicted of a position, as well. (NOTE: You will not automatically be excluded from consideration if you have been convicted of a crime. Your suitability for the position sought will be evaluated based upon the totality of circumstances such as the crime, the recency of the conviction, the type of work involved, etc.). I understand and agree that all information concerning patients and their families is strictly confidential. I am not permitted to disclose any financial, medical or personal information related to any patient or family member to fellow employees, company administrative staff or individuals, except my supervisor at Apex VIP Care, LLC. I authorize Apex VIP Care, LLC to investigate my employment history, credentials, license verification and to obtain any relevant information, including a criminal background check needed to make an employment decision. I authorize Apex VIP Care, LLC to disclose this application along state, federal, contractual or accreditation audit purposes. I also authorize Apex VIP Care, LLC to disclose any of my performance appraisals, disciplinary records or skills tests for the same purposes as above. I also understand and agree that passing a medical examination (which is my responsibility) and/or medical screening may be required. If medical restrictions cannot be reasonable accommodated, I may not be hired, or if hired, I may be terminated. I understand and agree that I may be subject to pre-employment drug testing and/or alcohol testing, random testing, as well as testing where reasonable suspicion or improper usage has occurred, or where warranted by an on-the-job injury, circumstance, workplace conditions or contractual requirements. I understand and agree nothing contained in this employment application or in granting of an interview creates an employment contract between Apex VIP Care, LLC and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me. If an employment relationship is established, I understand that my employment will be "at-will;" that is, I will have the right to terminate my employment at any time and that Apex VIP Care, LLC retains the same right to terminate my employment at any time. I understand that should I become employed by Apex VIP Care, LLC retains the same right to terminate my employment at any time. I understand that should I become employed by Apex VIP Care, LLC my work assignments, schedules and/or work locations are subject to change according to the needs of the business and the clients of Apex VIP Care, LLC. I understand that Apex VIP Care, LLC is committed to promoting safety and high standards of employee performance, productivity and reliability. In order to achieve this, I may be subjected to a drug test prior being hired to assure Apex VIP Care, LLC do not currently have narcotics, sedatives, stimulants or other controlled substances and/or mood-altering substances in my body. I understand if I have any such substance in my body at the time of the drug test, Apex VIP Care, LLC will not hire me. I understand that Apex VIP Care, LLC reserves the right to add to, change and/or delete their policies, procedures, work rules and benefits at anytime and that no one in Apex VIP Care, LLC has the authority to enter into an agreement for any particular period of time, or contrary to the above terms, unless that agreement is set forth in writing and signed by an authorized representative of Apex VIP Care, LLC. I acknowledge, I have read and understand the contract terms and conditions stated above.
*
Agreed
Todays Date
*
-
Month
-
Day
Year
Date
Signature
*
Please verify that you are human
*
Submit
Submit
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