Steadfast Home Healthcare Application for Caregivers

Steadfast Home Healthcare Application for Caregivers
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Employer
Years of Experience in Healthcare
Social Security Number
Highest Level of Education
Photo ID upload

Cancelof
Date Available to Begin Working

MonthDayYear
Date
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
If no, please list the state(s) you have lived in below.
YesNo
How did you learn about this position?
YesNo
If yes, please explain why.
If you are hired for the position of Personal Care Attendant (PCA), a background screening via the Family Care Safety Registry (FCSR) must be conducted prior to your first day of employment. Please read the following questions carefully and respond truthfully and fully.
YesNo
Disclose all criminal convictions, findings of guilt, and pleas of nolo contendere or provide a statement that there is no record of such background. Failure to disclose any criminal information is a violation of the law. If this does not apply, please use N/A. If Yes, Give Offense and Date for Each Crime:
Yes
Yes
YesNo
If Yes, please disclose all aliases and social security numbers that you have used.
YesNo
YesNo
If Yes, when?
YesNo
YesNo
YesNo
YesNo
If Yes, please explain.
Preferences and Availability
MalesFemalesEither
SundayMondayTuesdayWednesdayThursdayFridaySaturday
Bathing/ShoweringCleaningCorrespondenceDressing/GroomingErrandsFeedingHouseworkLaundryMeal PreperationToilet RoutineTransfersShopping
Employment History
Upload Resume

Cancelof
Company Name
Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Supervisor
Your Position
Date Started Job

MonthDayYear
Date
Last Day of Employment

MonthDayYear
Date
YesNo
What were your duties?
What was your reason for leaving?
YesNo
I certify that all of the information contained in the application is true and complete and I authorize verification of any or all information presented above.
Signature
Todays date of signing

MonthDayYear
Date
STEADFAST HOME HEALTHCARE LLC is an equal oppurtunity employer. In accordance with the Civil Rights Act of 1964, our agency does not discriminate in employment due to race, creed, religion, age, national origin or disability.
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Steadfast Home Healthcare Application for Caregivers

Preferences and Availability

Employment History