Apex VIP Care: Caregiver/ Staff Application Form

Apex VIP Care: Caregiver/ Staff Application Form

We are an Equal Opportunity Employer and committed to excellence through diversity.
Personal Information
Name

First NameLast Name
Your Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email
example@example.com
What is the best time to contact you?
Your Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you willing to attend in person orientation in the Jonesboro, GA office?
Are you currently legally entitled to work in the country where the job is based?
If applicable, please detail any restrictions:
Do You Have a Valid and Unrestricted Drivers License?
Do you have reliable transporation?
Have you ever been charged with a crime other than a traffic ticket?
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?
If hired, do you understand that you may be required to submit a drug test?
If hired, do you understand that you must have a current tuberculosis skin test or chest x-ray completed?
Is there any reason that you cannot be tested for tuberculosis?
Do you speak and understand the English Language?
Languages spoken other than English:
Position Information
What position are you applying for?
What is your desired employment?
Are you open to Per Diem/ as needed hours if full time is not available?
Georgia Counties You Are Availble to Accept Assignements In (Select all that apply):
What is your desired hourly pay?
Hourly
What is your available start date?

MonthDayYear
Date
Time of Day that you prefer to work:
Are you available to work Weekends and / or Holidays?
Do you have access to a smart device to clock in and out and document your shifts?Not required, but will help you submit your hours and tasks with less office visits.
What certification or professional license do you hold? CNA/ PCA/ HHA/ LPN/ RN: copies must be presented in person if offered employment
Certification or professional license number: (CNA/ PCA/ HHA/ LPN/ RN numbers)
Additional certification or professional license held:
Education
Start Date

MonthDayYear
Date
Graduation Date

MonthDayYear
Date
Start Date

MonthDayYear
Date
Graduation Date

MonthDayYear
Date
Work Experience

Please include up to past 5 years
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Manager/ Supervisor Name
Manager/ Supervisor Phone or Email:
Previous Job Description/ Duties:
Reason for leaving:
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Manager/ Supervisor Name
Manager/ Supervisor Phone or Email:
Previous Job Description/ Duties:
Reason for leaving:
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Manager/ Supervisor Name
Manager/ Supervisor Phone or Email:
Previous Job Description/ Duties:
Reason for leaving:
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Manager/ Supervisor Name
Manager/ Supervisor Phone or Email:
Previous Job Description/ Duties:
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Manager/ Supervisor Name
Manager/ Supervisor Phone or Email:
Previous Job Description/ Duties:
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Manager/ Supervisor Name
Manager/ Supervisor Phone or Email:
Previous Job Description/ Duties:
Qualifications
Microsoft Office
Communication Skills
SEO
References
Type a question
Optional Upload: Upload License/ Certification- CNA/ PCA/ LPN/ RN- Must present in person if hired

Cancelof
Optional Upload: Upload CPR, BLS and First Aid Certifications- Must present in person if hired

Cancelof
Optional Upload: Upload TB Test (Must be within 1 year) - Must present in person if hired

Cancelof
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.
Todays Date

MonthDayYear
Date
Signature
Please verify that you are human
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Apex VIP Care: Caregiver/ Staff Application Form

Personal Information

Position Information

Education

Work Experience

Qualifications

References