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Application

General Application Information

My desired starting rate is $ per hour

I am available for

FULL-TIME
PART-TIME
WEEKENDS
LIVE-IN
OVERNIGHT
MORNINGS
AFTERNOONS
EVENINGS

I was referred to this role by

I AM 18 YEARS OF AGE OR OLDER
I AM A US CITIZEN
I AM NOT A US CITIZEN

Are you lawfully authorized to work in the US?(Proof of citizenship or immigration status will be required upon employment.)

YES
NO

Have you been convicted of a felony or drug-related offense?

YES
NO

Please Explain

Are you capable of performing, with or without reasonable accommodation, the essential functions of the job for which you have applied?

YES
NO

Field Staff Information

I am allergic to

SMOKE
DOGS
CATS
OTHER

I have a

CAR
DRIVER'S LICENSE
INSURANCE
I CAN WORK WITH PETS

I would like to work as a

NA
COMPANION
PCA

I am available to work

MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
MORNINGS
AFTERNOONS
EVENINGS
OVERNIGHT
I CAN ACCEPT FILL-IN HOURS

For each region, select what shift length you would be willing to travel for.

North Wake County

12-HOUR SHIFT
8-HOUR SHIFT
3-4 HOUR SHIFT

West Wake County

12-HOUR SHIFT
8-HOUR SHIFT
3-4 HOUR SHIFT

Central Wake County

12-HOUR SHIFT
8-HOUR SHIFT
3-4 HOUR SHIFT

Winston-Salem

12-HOUR SHIFT
8-HOUR SHIFT
3-4 HOUR SHIFT

Greensboro

12-HOUR SHIFT
8-HOUR SHIFT
3-4 HOUR SHIFT

Durham

12-HOUR SHIFT
8-HOUR SHIFT
3-4 HOUR SHIFT
I CAN PROVIDE TRANSPORTATION FOR CLIENTS

I have experience with:

HOYER LIFT
CATHETER CARE
OSTOMY CARE
TOTAL CARE
DEMENTIA

Employment Information

Employer 1(Current/Most Recent)

I STILL WORK HERE

Supervisor(s) name

Reason for leaving:

Employer 2

Supervisor(s) name

Reason for leaving:

Employer 3

Supervisor(s) name

Reason for leaving:

Education Information

High School Education

I GRADUATED

College Education

I GRADUATED

Other College Education

I GRADUATED
I AM CURRENTLY ATTENDING CLASSES/SCHOOL

Skills & Abilities

I HAVE A VALID DRIVER'S LICENSE

In the past three years have you received any moving violations, or been involved in any vehicular accidents that were your fault?

YES
NO

Caregiver References and Final Remarks

Do not refer to relatives. Include only individuals familiar with your work ability.

Reference 1

Reference 2

Reference 3

Terms of Application

I certify that the facts contained in this application are true and complete. I understand that falsified statements on this application shall be considered cause for discharge.

I understand that any offer of contract made by At Home Eldercare is contingent upon the satisfactory results of a motor vehicle report and a criminal background check.

I further acknowledge and agree that my contract may be terminated, with or without prior notice, at any time, at the will of the Company or me, with or without cause.

No representative or employee of the Company, with the exception of the President, has the authority to enter into any contract or agreement with a client within two (2) years of termination from the Company. I also understand that if I enter into such a contract or agreement with a At Home Eldercare client, be it past or present, I will liable to the Company for damages up to $3,000.

This application will be maintained in the Company's active files for three months only, unless renewed.