A Carolina Homecare 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
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What position are you applying for?
*
Caregiver
Home Health Aide
Office Assistant
Other
Have you ever been charged with a felony or misdemeanor? If hired, you will be required to complete a background check.
*
Yes
No
If yes, please explain.
Please select all that apply to you:
*
Valid Driver's License
Current auto insurance
CPR Certified
CNA Certification
HHA Certification
Copy of recent TB results
Covid-19 Vaccination
Please upload a copy of Driver's License or ID
*
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Please upload a copy of your Social Security Card
*
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Please upload CPR and/or TB results if applicable
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Please upload any other relevant documents
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What specific shift/hours are you willing to work?
*
How many hours are you willing to work a week?
*
How much do you want to make an hour?
*
Are you willing to travel? If so, how far?
*
Are you willing to work weekends?
*
Every
Rotating
None
I am comfortable (select all that apply):
*
being around pets
being around dogs
being around cats
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 or transport clients)
*
Yes
No
Please list any other relevant information
Please list one professional reference: Name, phone number, and brief description of relationship
*
Please list one personal reference: Name, phone number, and brief description of relationship
*
If you are coming with a client, please list client's name and relationship to you. Example: John Doe- Father
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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