Senior Care Job Application

Personal Info.

First Name

Middle Name

Last Name

Email

Phone Number

Second Phone Number

Address

Street

City

State

Zip Code

Are you 18 years or older

Yes

No

Position Applying For

Personal Care Assistant (PCA)

Home Health Aide (HHA)

Nursing Assistant (CNA)

Companion

Homemaker

Availability

Days Available:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Shifts Available:

Morning

Afternoon

Evening

Overnight

Weekends only

Earliest Availability start date

Transportation & Experience

Emergency Contact

Name

Phone

Education and Certifications

Employment History

Start with the Most Recent Employer

Most Recent Employer

Company Name

Company Phone

Company Address

Job Title

Date: from. To.

May (SAC) contact your recent employer?

Yes

No

Second Employer

Company Name

Company Phone

Company Address

Job Title

Date: from. To.

Third Employer

Company Name

Company Phone

Company Address

Job Title

Date: from.

Professional References

First Reference

First Name

Last Name

Phone

Second Reference

First Name

Last Name

Phone

Third Reference

First Name

Last Name

Phone

Background, Compliance, and Acknowledgment

Have you ever been excluded, suspended, or barred from Medicare, Medicaid, or another government health care program?

No

Yes

If yes to any question above, explain.

Have you ever been substantiated for abuse, neglect, exploitation, or misappropriation?

No

Yes

If yes explain.

Have you ever been convicted of a crime, or do you currently have pending criminal charges?

No

Yes

If yes explain.

Certification and Consent

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 application termination.

I authorize Senior Affordable Care Llc to verify employment, references, credentials, and background information as permitted by law. I understand that employment is contingent upon completion of required onboarding, training, background checks, and document verification.

I have read and agree to the Certification and Consent statement above.

Application Date

Upload Documents

For security, upload only clear copies requested for employment review.
Photo ID, Drivers license, Social Security Card and other Certifications must be readily available at the interview and orientation (On-boarding)

Draw Signature

Job Application Form

Personal Info.

Position Applying For

Availability

Transportation & Experience

Emergency Contact

Education and Certifications

Employment History

Professional References

Background, Compliance, and Acknowledgment

Certification and Consent