PREMIER CARE PARTNERS
Premier Care Partner Application
Electronic Employment Application - Confidential
Thank you for your interest in joining Premier Care Partners. We seek dependable, compassionate professionals who demonstrate dignity, reliability, confidentiality, sound judgment, and respect for each client's individualized care plan.
1. Applicant Information
Full Legal Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State/Zip Code
Phone
Format: (000) 000-0000.
Email
example@example.com
Earliest Available Start Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
2. Position & Availability
Position Desired
Care Partner / Companion
Hospital Sitter
Transportation / Errands
Personal Care / ADL Support
Respite Care
Other
Desired Schedule/ Availability- Select all that apply
Full-time
Part-time
PRN/ As Needed
Days
Evenings
Nights
Weekends
Specific Days / Hours Available
Approximate Hours Desired per Week
3. Employment Eligibility
Premier Care Partners is an equal opportunity employer. Please answer only the job-related questions below.
Legally authorized to work in the United States?
Yes
No
At least 18 years of age?
Yes
No
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PREMIER CARE PARTNERSCARE PARTNER EMPLOYMENT APPLICATION
Electronic Employment Application - Confidential
4. Education, Training & Credentials
Highest Level of Education / School
Caregiving / Healthcare Training
CNA or Other Credential (type / state / expiration)
CPR / First Aid (provider / expiration)
Other Relevant Certification / Training
Do not upload sensitive identity documents with this application unless Premier Care Partners specifically requests them through an approved process.
5. Caregiving Experience
Years of Caregiving / Related Experience
Caregiving Experience Types
Older adults
ADL / personal care
Post-discharge support
Meal preparation
Respite
Dementia / memory care
Hospital sitter
Mobility issues
Companionship/ Social support
Briefly describe your most relevant caregiving experience
6. Employment History - Most Recent Employer
Employer
Job Title
Dates Employed
Supervisor / Contact
First Name
Last Name
Employer Phone
Format: (000) 000-0000.
May we contact this employer?
Yes
No
Reason for Leaving
Primary Duties
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PREMIER CARE PARTNERS
CARE PARTNER EMPLOYMENT APPLICATION
Electronic Employment Application - Confidential
7. Additional Employment History
Previous Employer #2
Employer
Job Title
Dates Employed
Employer Phone
Format: (000) 000-0000.
Reason for Leaving / Primary Duties
Previous Employer #3
Employer
Job Title
Dates Employed
Employer Phone
Format: (000) 000-0000.
Reason for Leaving / Primary Duties
8. Professional References
Reference 1
Name / Relationship
First Name
Last Name
Phone / Email
Reference 2
Name / Relationship
First Name
Last Name
Phone / Email
Reference 3
Name / Relationship
First Name
Last Name
Phone / Email
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PREMIER CARE PARTNERSCARE PARTNER EMPLOYMENT APPLICATION
Electronic Employment Application - Confidential
9. Transportation & Job Requirements
Some assignments may require reliable transportation or authorized client transportation. A driver's license and appropriate automobile insurance will be verified only when relevant to the assignment.
Do you have reliable transportation to report to assigned client locations?
Yes
No
If required for an assignment, are you willing to drive a client or complete authorized errands?
Yes
No
If driving is required for an assignment, can you provide proof of a valid driver's license and appropriate insurance?
Yes
No
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PREMIER CARE PARTNERSCARE PARTNER EMPLOYMENT APPLICATION
Electronic Employment Application - Confidential
10. Applicant Disclosures
Answer the following truthfully. A response does not automatically disqualify an applicant. Premier Care Partners evaluates job-related information consistent with applicable law and company policy.
Have you previously worked for Premier Care Partners?
Yes
No
Do you have a relative currently employed by Premier Care Partners?
Yes
No
Can you perform the essential functions of the position for which you are applying, with or without reasonable accommodation?
Yes
No
Can you reliably meet the availability you listed on this application?
Yes
No
If explanation is needed for any answer above, please explain below:
11. Applicant Certification & Electronic Signature
I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that material misrepresentation or omission may affect consideration for employment or, if employed, may result in corrective action up to and including termination, consistent with applicable law. I authorize Premier Care Partners to contact the employers and professional references I have listed for employment-related verification. I understand that this application is not an employment contract and does not guarantee employment.
By typing my full legal name below, I intend this entry to serve as my electronic signature for this application. Premier Care Partners may use a separate compliant authorization for any consumer/background report and any other screening that requires separate notice or consent.
Electronic Signature - Full Legal Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Application
Should be Empty: