Application for Employment

Application for Employment

Personal Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date Available to Start

MonthDayYear
Date
Position Applied
Social Security Number:
Are you legally eligible to work in the U.S.?
Have you ever worked for this employer?
If yes, write start and end dates
Are you willing to consent to a background check?
Have you ever been convicted of a felony?
If yes, please explain

Education:
High School:
City / State
Graduated?
College:
City / State
Graduated?
If yes, type of degree:

Previous Employment:
Employer 1:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Starting Pay:
Job Title:
Dates of Employment:
Job Responsibilities:
Reason for leaving:
Employer 2:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Starting Pay:
Job Title:
Dates of Employment:
Job Responsibilities:
Reason for leaving:

Personal References:
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Relationship:
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Relationship:
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Relationship:

Applicant Certification, Authorization, and Equal Opportunity Statement

MMJ Home Care Solutions, Inc. is an Equal Opportunity Employer. We are committed to providing equal employment opportunities to all applicants and employees and do not discriminate on the basis of race, color, religion, sex, national origin, age, disability, genetic information, veteran status, or any other protected status under applicable federal, state, or local laws.

I certify that the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that any false statements, omissions, or misrepresentations may result in the rejection of my application or termination of employment if discovered at a later date.

I understand that submitting this application does not constitute a contract or guarantee of employment. If hired, I understand that my employment will be at-will, meaning that either I or the company may terminate the employment relationship at any time, with or without cause or notice, as permitted by law.

I authorize MMJ Home Care Solutions, Inc. to verify the information provided in this application and to conduct lawful background checks, reference checks, and employment verification as necessary to evaluate my qualifications for employment.

By signing below, I acknowledge that I have read and understand the statements above.
Signature:

MMJ Home Care Solutions, Inc. Hepatitis B Vaccine Declination Form

I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HBV) infection.

I have been given the opportunity to be vaccinated with the Hepatitis B vaccine at no charge to myself. However, I decline the Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with the Hepatitis B vaccine, I can receive the vaccination series at no charge to me.
Signature
Print Full Name

MMJ Home Care Solutions, Inc. Authorization to Contact References
I hereby authorize MMJ Home Care Solutions, Inc. to contact the references listed in my application, as well as previous employers, supervisors, and other individuals who may have knowledge of my work history, qualifications, and character.

I authorize these individuals and organizations to provide information concerning my previous employment, job performance, professional conduct, and qualifications for employment.

I release MMJ Home Care Solutions, Inc., its representatives, and all individuals or organizations providing information from any liability arising from the exchange of such information for the purpose of evaluating my application for employment.

I understand that this authorization will remain valid for the duration of the hiring process.
Signature
Date

MonthDayYear
Date

MMJ Home Care Solutions, Inc. Background Check Disclosure and Authorization
DISCLOSURE REGARDING BACKGROUND INVESTIGATION MMJ Home Care Solutions, Inc. may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report,” which may include information about your character, general reputation, personal characteristics, criminal history, and employment history. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment for employment-related purposes as permitted by law.

AUTHORIZATION I authorize MMJ Home Care Solutions, Inc. to obtain consumer reports and/or investigative consumer reports about me for employment purposes. I understand that these reports may include criminal background information, verification of employment, reference checks, and other information relevant to my qualifications for employment. I authorize all persons, schools, employers, law enforcement authorities, and other organizations to release any information requested by the consumer reporting agency or MMJ Home Care Solutions, Inc. in connection with this investigation. I understand that my employment may be contingent upon satisfactory completion of the background screening.
Full Name:

FirstLast
Social Security Number:
Date of birth:
Driver's License Number:
Issuing State:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email Address:
example@example.com

In-Home Caregiver Job Description
MMJ Home Care Solutions, Inc.

Position Title: In-Home Caregiver / Personal Care Aide

Position Summary: The In-Home Caregiver provides non-medical personal care and supportive services to clients in their homes in accordance with the established plan of care. Caregivers assist clients with activities of daily living while promoting dignity, independence, safety, and quality of life.

All caregivers work under the direction, instruction, and supervision of the Service Supervisor (Registered Nurse)and must follow the client’s individualized service plan.

Responsibilities: The In-Home Caregiver may perform the following duties based on the client’s approved service plan:

Personal Care Assistance

• Assistance with bathing, grooming, and personal hygiene

• Assistance with dressing and undressing

• Assistance with toileting and incontinence care

• Assistance with mobility, ambulation, and transfers

• Assistance with feeding and meal preparation

Household Support

• Light housekeeping related to the client’s care

• Laundry and linen changes

• Dishwashing and kitchen cleanup

• Maintaining a clean and safe environment

Client Support

• Providing companionship and emotional support

• Assisting with reminders for medications (not administering medication)

• Assisting with grocery shopping and errands if authorized

• Observing and reporting changes in the client’s condition to the Service Supervisor

Documentation

• Accurately documenting care provided during each shift

• Maintaining required electronic visit verification (EVV) or documentation procedures

• Reporting incidents, concerns, or safety issues promptly

Professional Conduct

• Maintaining confidentiality and protecting client privacy

• Treating clients with dignity and respect at all times

• Following agency policies and procedures

Qualifications

• Assistance with bathing, grooming, and personal hygiene

• Assistance with dressing and undressing

• Assistance with toileting and incontinence care

• Assistance with mobility, ambulation, and transfers

• Assistance with feeding and meal preparation

Household Support

• Light housekeeping related to the client’s care

• Laundry and linen changes

• Dishwashing and kitchen cleanup

• Maintaining a clean and safe environment

Client Support

• Providing companionship and emotional support

• Assisting with reminders for medications (not administering medication)

• Assisting with grocery shopping and errands if authorized

• Observing and reporting changes in the client’s condition to the Service Supervisor

Documentation

• Accurately documenting care provided during each shift

• Maintaining required electronic visit verification (EVV) or documentation procedures

• Reporting incidents, concerns, or safety issues promptly

Professional Conduct

• Maintaining confidentiality and protecting client privacy

• Treating clients with dignity and respect at all times

• Following agency policies and procedures

Job Conditions

• Work is performed in the client’s home environment

• May require standing, walking, bending, lifting, and transferring clients

• Exposure to pets, smoke, or varying household environments may occur

• May require lifting up to 50 pounds with proper technique

• Flexible schedules may include evenings, weekends, or holidays

• Travel between client homes may be required

Qualifications

• Must be at least 18 years of age

• High school diploma or GED preferred

• Previous caregiving experience preferred but not required

• Ability to read, write, and communicate effectively

• Must pass required background screening and registry checks

• Must demonstrate compassion, reliability, and professionalism

• Ability to follow instructions and work under the supervision of the Service Supervisor (RN)

Additional requirements may include:

• Valid driver’s license and reliable transportation (if applicable)

• Ability to complete required training and orientation

• Ability to safely perform caregiving tasks and physical requirements of the job

Job Description Acknowledgment

I acknowledge that I have received, read, and understand the job description for the position of In-Home Caregiver with MMJ Home Care Solutions, Inc. I understand that I will perform my duties under the direction, instruction, and supervision of the Service Supervisor (Registered Nurse) and in accordance with the client’s plan of care and agency policies.

I understand that this job description is not intended to be a complete list of all responsibilities and that additional duties may be assigned as necessary to meet the needs of clients and the agency.
Full Name

First Last
Signature

Identification Requirement

Please upload two (2) forms of identification as part of your application.

Required documents include:

• A clear photo of the front and back of your Driver’s License or State Identification Card

• A clear photo of your Social Security Card

All images must be clear, legible, and show the entire document. Blurry, cropped, or incomplete images may delay the review of your application.
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Application for Employment

Education:

Previous Employment:

Personal References:

MMJ Home Care Solutions, Inc. Authorization to Contact References

MMJ Home Care Solutions, Inc. Background Check Disclosure and Authorization

In-Home Caregiver Job Description