Heartbound Home Care, LLC Employment Screening Form
Please complete all sections to be considered for employment. All information will be kept confidential.
Basic Information
Please provide your contact and certification details.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Certification Level
*
Please Select
CNA
PCA
LPN/RN
Companion/Sitter
Do you have a valid Georgia Driver’s License and reliable, insured transportation?
*
Yes
No
Georgia Compliance Screening
Please answer the following compliance questions.
Do you have a negative TB test result from the last 12 months?
*
Yes
No
Are you CPR and First Aid certified?
*
Yes
No
Do you consent to a state-mandated fingerprint background check via GCHEXS?
*
Yes
No
Professional History
Provide two professional references and their contact information.
Professional Reference #1 Name
*
Professional Reference #1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Professional Reference #2 Name
*
Professional Reference #2 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you legally authorized to work in the United States for any employer?
YES
NO
Legal Disclaimer and Consent
Please review the following legal statement and provide your electronic signature.
[Enter your legal disclaimer text here. This area is for important legal statements, terms, or consent. You may edit this placeholder with your specific disclaimer wording.]
*
Applicant Certification & Release of Information Please read the following statements carefully before signing: Truthfulness of Information: I certify that all information provided in this employment application is true, complete, and correct to the best of my knowledge. I understand that any misrepresentation, falsification, or omission of facts may result in the rejection of my application or, if employed, immediate termination of employment, regardless of when the falsification is discovered. Employment-at-Will: I understand and agree that, if hired, my employment with Heartbound Home Care, LLC is "at-will." This means that either I or Heartbound Home Care, LLC may terminate the employment relationship at any time, with or without cause, and with or without notice, subject to applicable federal and state laws. Background & Reference Consent: I authorize Heartbound Home Care, LLC to investigate my personal and professional history, including but not limited to my criminal record, driving record, and previous employment. I release Heartbound Home Care, LLC and all individuals or entities providing such information from any and all liability or claims for damages in relation to the investigation or the information provided. Georgia Caregiver Portal & GCHEXS: I acknowledge my rights regarding non-criminal justice privacy and specifically consent to having my information entered into the Georgia Caregiver Portal. I understand that a satisfactory fingerprint-based background check via the Georgia Criminal History Check System (GCHEXS) is a mandatory condition of employment. HIPAA & Confidentiality: I understand that as a healthcare entity, Heartbound Home Care, LLC handles Protected Health Information (PHI). If hired, I agree to strictly adhere to all HIPAA regulations and company privacy policies to maintain client confidentiality. Drug-Free Workplace: I understand that Heartbound Home Care, LLC maintains a drug-free workplace. I consent to pre-employment and/or random drug screening as a condition of my continued employment. By providing my electronic signature below, I acknowledge that I have read, understand, and agree to the terms listed above.
E-Signature (Type or sign your name)
*
Submit Application
Submit Application
Should be Empty: