• Georgina Home Care Assistance

    Job Application Form

    Please Fill Out the Form Below to Submit Your Job Application!
  • Format: (000) 000-0000.
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  • Have you ever been employed here before?*
  • Are you a smoker?*
  • Are you prevented from lawfully becoming employed in this country because of visa or immigration status? (proof of citizenship status may be required upon employment)*
  • Have you been convicted of a felony in the last 7 years? (Conviction will not necessarily disqualify applicant from employment*
  • Primary Languages*
  • Do you have a car and valid Driver's License?*
  • Desired Shift*
  • Days of Availability*
  • Which of the following skills are you experienced with? (Select all that apply)*
  • Are you able to perform the essential functions of this job with or without reasonable accommodations?*
  • Are you interested in Direct Deposit?*

  • As a condition of employment, I authorize Georgina Home Care LLC or any investigative service to investigate my background on a regular basis, to determine suitability for employment or to determine if continued employment is feasible. I understand that the inclusion of any false or misleading information, or omission of information on my application or during employment is based on the

     

    State Criminal Conviction Check
    National Criminal Background Check
    DDS Abuse/Neglect Registry Checks
    State and National Sex Offender Registry Checks
    Office Inspect General Exclusions Database Check
    Quality Assurance Actions List Check 
    Other pertinent background checks that may be deemed necessary by our state regulations. 

    I have reviewed this form, fully understand the intent of this authorization, and give my full consent for disclosure of all my records (whether personal or otherwise) from current and/or previous employment, educational institutions, the Department of Motor Vehicles, criminal and law enforcement agencies, and military records (which include a copy of my DD-214 Separation Form)


    I fully understand that the information provided by the agent is secure only as to what was provided to them, therefore, do not hold the agent, nor Georgina Home Care LLC liable in any way. I release Georgina Home Care LLC from liability for damages that I may incur, which may result from the release/use of this information.


    A photocopy of this release will be valid as the original, even though the said photocopy copy does not contain an original writing of my signature. 

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