Job Application
Apply for a position at True Care Private Care Enterprise, LLC. Please provide your details below. All fields are required.
Full Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
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Number of years at this address
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Social Security Number
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Driver License Number
*
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Emergency Contact Name
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First Name
Last Name
Emergency Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact-Relationship
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Emergency Contact Address
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Street Address
Street Address Line 2
City
State / Province
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Application Questions
Job Title Applying For
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Please Select
PCA
CNA
RN-1099
Job Position Applying For
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Please Select
PRN
Full-Time
Part-Time
Servicing Location Applying For
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Who referred you to the company?
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Do you have any friends or relatives who work here? If yes, please list:
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Yes
No
Other
Are you at least 18 years old?
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Yes
No
Are you legally authorized to work in the U.S?
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Yes
No
Do you have any felonies?
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Yes
No
Do you have the means of transportation to get to work?
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Yes
No
Do you have the means of transportation to get to work?
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Yes
No
Are you willing to work any shift, including nights and weekends (if available). If no, please state any limitations
Availability (days and times you can work)
If applicable, are you available to work overtime?
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Yes
No
If you are offered employment, when would you be available to begin work?
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Month
-
Day
Year
Date
If you are offered employment, are you willing to drive over the standard 30 mile radius, with mileage pay?
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Yes
No
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Applicant Skill Set: Check those skills that you have. List any other skills that may be useful for the job you are seeking. Enter the number of years of experience and circle the number which corresponds to your ability for each skill. (One represents poor ability, while five represents exceptional ability.)
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Rows
Years of experience
Rating (1-5)
Typing
Microsoft Office ( Word, Excel etc)
Accounting/Bookkeeping
Answering Telephones
Filing
Customer Service
Charting (Digital or Paper)
Adaptability
Communication
Interpersonal
Time-Management
Teamwork
Conflict-Resolution
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Applicant Employment History
List your current or three most recent employment first. Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent, and list and explain any gaps in employment. If additional space is needed, continue the back page of this application.
1. Employer Name
*
1. Supervisor Name
*
First Name
Last Name
1. Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
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Reason for leaving?
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Date of employment?
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Month
-
Day
Year
Date
2. Employer Name
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2. Supervisor Name
*
First Name
Last Name
2. Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job Title
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Reason for leaving?
*
Date of employment?
*
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Month
-
Day
Year
Date
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Applicant Education and Training
High School/GED Name and Address
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If not applicable, annotate (N/A)
College/University Name and Address
*
If not applicable, annotate (N/A)
Did you receive a degree?
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Yes
No
Other Training (graduate, technical, vocational):
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If not applicable, annotate (N/A)
Please indicate any current professional licenses or certifications that you hold
*
If not applicable, annotate (N/A)
Awards, Honors, Special Achievements:
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If not applicable, annotate (N/A)
Military Service/Branch
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If not applicable, annotate (N/A)
Specialized Training:
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If not applicable, annotate (N/A)
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Professional References
List any two non-relative/professional references who would be willing to provide a reference for you.
1. Reference
*
First Name
Last Name
1. Reference Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
1. Reference Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
*
2. Reference
*
First Name
Last Name
2. Reference Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
2. Reference Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
*
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CERTIFICATION
True Care Private Care Enterprise, LLC, reserves the right to establish personalized policies and procedures. To maintain healthy, productive, and trustworthy employees, True Care Private Care Enterprise, LLC implements listed clauses.
HIPAA Acknowledgment: I understand and agree to comply with all HIPAA privacy and security requirements.
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I acknowledge and agree
I do not acknowledge or agree
Background Check Consent: I authorize True Care Private Care Enterprise, LLC to conduct a background check as part of my application or further for employment (if hired).
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I consent
I do not consent
As a condition of employment, you agree to submit to random drug testing if hired
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I consent
I do not consent
As a condition of employment, you agree to stay current with all continuing education units offered by True Care Private Care Enterprise, LLC.
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I acknowledge and agree
I do not acknowledge or agree
If hired, you agree to avoid any intentional actions that may create conflict between True Care Private Care Enterprise, LLC, and other home healthcare agencies
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I acknowledge and agree
I do not acknowledge or agree
If hired, and previously employed by another home healthcare agency, you will not bring or implement their policies and procedures within this organization.
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I acknowledge and agree
I do not acknowledge or agree
If hired, you agree to maintain a workplace free from sexual harassment, discrimination, and any form of racial or religious intolerance. Such behavior will not be tolerated by either the employee or the employer.
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I acknowledge and agree
I do not acknowledge or agree
If hired, you are responsible for purchasing your own uniforms. True Care Private Care Enterprise, LLC requires adherence to the established dress code for every shift
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I acknowledge and agree
I do not acknowledge or agree
If hired by True Care Private Care Enterprise, LLC, any equipment provided to you in good condition must be returned in the same condition. You will be responsible for replacing any damaged or unreturned equipment
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I acknowledge and agree
I do not acknowledge or agree
If your employment is terminated or you resign before completing the 90-day probationary period, the cost of CPR/First Aid certification and the background check ($78.00), if paid by the company, will be deducted from your final paycheck
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I acknowledge and agree
I do not acknowledge or agree
I certify that the information provided on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination. I authorize True Care Private Care Enterprise LLC to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to communicate information fully and freely regarding my previous employment, attendance, and grades. I authorize those persons designated as references to communicate information fully and freely regarding my previous employment and education.
*
I acknowledge and agree
I do not acknowledge or agree
I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND AND AGREE TO ITS TERMS.
*
I acknowledge and agree
I do not acknowledge or agree
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REQUIRED DOCUMENTS
THIS APPLICATION IS CONSIDERED INCOMPLETE IF ALL REQUIRED DOCUMENTS ARE NOT FILLED ENTIRELY. FAILURE TO COMPLETE ALL REQUIRED DOCUMENTS CAN RESULT IN DENIAL OF POSSIBLE ACCEPTANCE, WITH THE EXCEPTION OF THE APPLICANT’S CPR CERTIFICATION AND TB RESULTS
RESUME
*
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DRIVERS LICENSE
*
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CPR CERTIFICATION
*
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If you do not obtain a certification the applicant is responsible for payment of certification through company’s CPR trainer
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CNA CERTIFICATION
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IF APPLICABLE
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NEGATIVE TUBERCULOSIS SKIN TEST (TB)
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Results must show negative. If applicant does not possess a TB skin test, applicant is responsible for payment and must provide company with scheduled date of exam and reading results
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BACKGROUND CHECK
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ANY OTHER CERTIFICATIONS
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PRELIMINARY QUESTIONS
What experience do you bring to our company?
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Can you describe your previous work experience related to this role?
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Tell me about a project or accomplishment you’re most proud of — what was your role?
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How do you stay current in your field?
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Tell me about a time you faced a major challenge at work — how did you handle it?
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Describe a time you had to make a quick decision without all the information.
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Are you already employed full time or part time with another agency? If yes, what are your hours there?
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Are you already employed full time or part time with another agency? If yes, what are your hours there?
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Is your employment with us intended to be secondary? If yes, we require the other agency/employer’s schedule at least 7 days in advance to generate our schedule.
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Are there days in which you cannot be scheduled with True Care?
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Are you familiar with non-compete policies within healthcare agencies? If not, please note the following policy: If your employment with True Care ends—whether through resignation or termination—you may not solicit or provide services to True Care patients independently. Additionally, employees are not permitted to contact patients outside of business hours. All patient communication must be conducted through True Care. Do you understand and agree to this policy?
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I HAVE CAREFULLY ANSWERED THE PRELIMINARY QUESTIONS CAREFULLY AND TRUTHFULLY .
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I acknowledge and agree
I do not acknowledge or agree
Date
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Month
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Day
Year
Date
Signature
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Submit Application
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