Employment Application

iCherish Home Care Services — Application for Employment

Review the employment application terms and complete all required sections.
iCherish Home Care Services
953 Harmony Rd, Suite 202, Eatonton, GA 31024 | Office: 762-815-3003
Georgia Licensed Private Home Care Provider | Care With Purpose

Thank you for your interest in joining our team. Please complete every section of this application. Applicants are considered without regard to race, religion, color, national origin, age, sex, disability, sexual orientation, or veteran's status.

Any offer of employment is conditional and subject to a fingerprint-based criminal history records check, drug and alcohol testing, satisfactory references, tuberculosis screening, and successful completion of required orientation and training.
Section 1 — Applicant Information
Full legal name

First NameLast Name
Any other names you have used
Home address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Cell phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate phone
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Date of birth

MonthDayYear
Date
Social Security number
Are you 18 years of age or older?
Are you legally authorized to work in the United States?
Have you ever applied for a position with iCherish Home Care Services before?
If yes, approximately when did you apply?
Have you ever been employed by iCherish Home Care Services before?
If yes, what were your dates of employment and position?
Are you currently employed?
If currently employed, may we contact your present employer?
Section 2 — Position and Availability
Date of application

MonthDayYear
Date
Position applied for
Employment type sought
Date available to begin work

MonthDayYear
Date
Shifts and days available
Counties you are willing to work in
How did you hear about us?
Referral source name, if applicable
Section 3 — Education, Credentials and Training
Highest level of education completed
Name and location of school
Do you hold a current Georgia nursing license?
If licensed, provide your Georgia license number and expiration date
Do you hold a current Certified Nursing Assistant (CNA) or Personal Care Aide (PCA) certification?
If certified, provide the certifying body, certificate number, and date obtained
Have you completed a Personal Care Aide training program?
Do you hold a current CPR certification?
If yes, provide certifying organization and expiration date
Do you hold a current First Aid certification?
If yes, provide certifying organization and expiration date
Date of your most recent tuberculosis (TB) screening

MonthDayYear
Date
Do you have experience caring for clients with dementia or Alzheimer's disease?
If yes, briefly describe your experience
If yes, how many training hours did you complete?
Section 4 — Driving, Vehicle and Insurance

Complete this section if you may transport or escort clients, or drive for any work purpose.
Do you have a valid driver's license?
Driver's license number
State of issue
Driver's license expiration date

MonthDayYear
Date
Do you have reliable transportation?
Are you willing to transport or escort clients in your own vehicle?
Do you carry current automobile liability insurance?
Insurance carrier and policy number
Policy expiration date

MonthDayYear
Date
Have you had any motor vehicle accidents in the past three years?
If yes, how many?
Have you had any moving violations in the past three years?
If yes, how many?
Section 5 — Five-Year Employment History

You must account for ALL of the past five years, beginning with your most recent position and working backward. This includes any period when you were not working. Georgia licensing regulations require a complete five-year history for every employee, and your application cannot be processed until every period is accounted for.
Were there any periods during the past five years when you were NOT employed?
Most Recent Employer — Name
Most Recent Employer — City and State
Most Recent Employer — Phone and Supervisor Name
Most Recent Employer — Your Job Title and Duties
Most Recent Employer — Dates Employed (from month/year to month/year)
Most Recent Employer — Reason for Leaving
Second Employer — Name
Second Employer — City and State
Second Employer — Phone and Supervisor Name
Second Employer — Your Job Title and Duties
Second Employer — Dates Employed (from month/year to month/year)
Second Employer — Reason for Leaving
Third Employer — Name
Third Employer — City and State
Third Employer — Phone and Supervisor Name
Third Employer — Your Job Title and Duties
Third Employer — Dates Employed (from month/year to month/year)
Third Employer — Reason for Leaving
Fourth Employer — Name
Fourth Employer — City and State
Fourth Employer — Phone and Supervisor Name
Fourth Employer — Your Job Title and Duties
Fourth Employer — Dates Employed (from month/year to month/year)
Fourth Employer — Reason for Leaving
Fifth Employer — Name
Fifth Employer — City and State
Fifth Employer — Phone and Supervisor Name
Fifth Employer — Your Job Title and Duties
Fifth Employer — Dates Employed (from month/year to month/year)
Fifth Employer — Reason for Leaving
Sixth Employer — Name
Sixth Employer — City and State
Sixth Employer — Phone and Supervisor Name
Sixth Employer — Your Job Title and Duties
Sixth Employer — Dates Employed (from month/year to month/year)
Sixth Employer — Reason for Leaving
Additional employers, if you have more than six
List any remaining positions from the past five years here, including employer name, city and state, phone, job title, dates, and reason for leaving.
Employment Gap 1 — Dates (from month/year to month/year)
Employment Gap 1 — What were you doing during this period?
Employment Gap 2 — Dates (from month/year to month/year)
Employment Gap 2 — What were you doing during this period?
Employment Gap 3 — Dates (from month/year to month/year)
Employment Gap 3 — What were you doing during this period?
Section 6 — Professional References
Reference 1 — Name

First NameLast Name
Reference 1 — Relationship to you
Reference 1 — Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Reference 1 — Email address
example@example.com
Reference 2 — Name

First NameLast Name
Reference 2 — Relationship to you
Reference 2 — Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2 — Email address
example@example.com
Reference 3 — Name

First NameLast Name
Reference 3 — Relationship to you
Reference 3 — Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Reference 3 — Email address
example@example.com
Section 7 — Statement of No Misconduct
In accordance with Georgia rules for private home care providers, applicants must disclose whether they have ever been the subject of any finding of abuse, neglect, or exploitation of a patient, client, or resident, or misappropriation of their property.
Have you ever been convicted of, or pleaded guilty or no contest to, any crime other than a minor traffic violation?
If yes, provide the date, jurisdiction, offense, and disposition
Have you ever been the subject of a finding of abuse, neglect, or exploitation of a patient, client, or resident, or misappropriation of their property?
If yes, explain
Are you listed on any state nurse aide registry with a finding of abuse, neglect, or misappropriation?
Section 8 — Authorizations
I authorize iCherish Home Care Services to conduct a fingerprint-based criminal history records check as required by Georgia law.
I authorize iCherish Home Care Services to contact my former employers and references, and I release them from liability for information provided in good faith.
I understand that any offer of employment is conditional upon satisfactory results of a criminal background check, drug and alcohol testing, and tuberculosis screening.
Section 9 — Document Uploads
Upload a copy of your driver's license or state-issued ID

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Upload your CNA/PCA certificate or nursing license, if applicable

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Upload your CPR/First Aid certification, if applicable

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Upload your TB screening results, if available

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Upload your resume, if available

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Section 10 — Acknowledgment and Signature
I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that false or misleading information may result in refusal to hire or termination of employment. I understand that this application is not a contract of employment and that employment with iCherish Home Care Services is at-will.
Signature
Date signed

MonthDayYear
Date
I understand that any offer of employment is conditional upon satisfactory results of a criminal background check, drug and alcohol testing, and tuberculosis screening.
I authorize iCherish Home Care Services to contact my former employers and references, and I release them from liability for information provided in good faith.
I authorize iCherish Home Care Services to conduct a fingerprint-based criminal history records check as required by Georgia law.
Employment History
Explanation of Employment Gaps
Should be Empty:

iCherish Home Care Services — Application for Employment

Section 1 — Applicant Information

Section 2 — Position and Availability

Section 3 — Education, Credentials and Training

Section 4 — Driving, Vehicle and Insurance

Section 5 — Five-Year Employment History

Section 6 — Professional References

Section 7 — Statement of No Misconduct

Section 8 — Authorizations

Section 9 — Document Uploads

Section 10 — Acknowledgment and Signature