Personal Information

First Name *

Middle Initial *

Last Name *

Date of birth *

Email *

Available Start Date *

Primary Phone *

Address *

Street Address

City

State

Postal code

Social Security Number *

Gender *

Male

Female

Undisclosed

Height *

Weight *

Languages *

Position Applying For *

Preferred Shift Length (Hrs) *

How many miles will you travel for an assignment? *

100

Desired Salary *

Please check all that apply *

I am a U.S citizen

I am authorized to work in the United States

I have previously worked for this company

Have you been convicted of a felony? *

Driving History

As part of the background screening process, a check of your driving record may be requested by a family seeking your services. Failure to disclose tickets or an accident will cause your application to be immediately rejected.

Vehicle Year | Make | Model | Color *

Driving Incidents

DUI within last 3 yrs?

Reckless driving ticket within 3 yrs?

Moving violations within 3 yrs?

Accidents in last 3 yrs?

If "YES" to any of the above, please explain.

Ability to Transfer

Do you have any physical limitations? *

Yes- Explain | No

Can you stoop, bend, and lift? *

Yes | No- Explain

Education

HIGH SCHOOL

High School Name/ GED *

High School Address *

From Date *

To Date *

Graduated *

Yes

COLLEGE

College Name

College Address

College From Date

College to Date

College Degree/ Did you Graduate?

EMPLOYMENT HISTORY

Most Recent Employment

Most Recent Company Name *

Most Recent Supervisor Name *

Employer Contact *

Job Position Most Recent *

Job 1 Date From *

Job 1 Date To *

Responsibilities Most Recent *

May we contact this supervisor for reference? *

Yes

Previous Position

Previous Company Name *

Previous Position *

Previous Supervisor Name *

Previous Supervisor Contact *

Job 2 Date From *

Job 2 Date To *

Previous Job Responsibilities *

May we contact this previous supervisor for reference? *

Yes

EMERGENCY CONTACT

Emergency Contact *

Emergency Contact Relationship *

Emergency contact Phone Number *

REFERENCES

Reference Name *

Reference Relationship *

Reference Contact *

Reference Company Name *

Reference Email *

REFERENCE 2

Reference 2 Name *

Reference 2 Relationship *

Reference 2 Contact *

REFERENCE 3

Reference 3 Name *

Reference 3 Relationship *

Reference 3 Contact *

File Upload *

Resumes File Upload

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

File Upload 2

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

File Upload 3

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

We are an equal opportunity home care referral agency. All applicants will be considered for caregiving opportunities without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.

Applicant Certification

Please read carefully before signing /submitting.

I authorize any of the persons or organizations referenced in this application to provide you with any and all information concerning my previous employment, education, or any other information they may have—personal or otherwise—with regard to any of the subjects covered by this application. I release all such parties from any liability for any damage that may result from furnishing such information to you. I authorize you to request and receive such information.

I understand that my contract is contingent upon verification of past employment, school transcripts, licensure, certifications, and a satisfactory criminal background check. I hereby consent to such examinations and verifications.

I further understand that I will be required to participate in direct deposit at a bank of your choosing for all payroll transactions.

I certify that the answers given herein are true and complete to the best of my knowledge. I understand that any misrepresentations, omissions of fact, or incomplete answers in any application document may disqualify me from further consideration as a subcontractor. I further understand that, if contracted, any misrepresentations or omissions of fact in any application document will be cause for my contract to be terminated at any time without prior notice.

I understand that my contract may be terminated if I, at any time, reveal confidential information concerning the organization, patients, or fellow team members.

Signature Required *

Clear

By checking this box, I consent to receive non-marketing text messages from Paradigm Home Care Inc. including interview reminders, scheduling updates, and follow-up messages. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.