Job Application

A Special Place Home Care

Now Hiring for Caring and Reliable Home Care Personnel

Job Application Form - Job Application Page

Applying For*

City/Town Applying For*

Full Name*

Address*

City*

Zip Code*

State*

Email*

Phone*

Employment

Are you legally eligible for employment in the U.S.A.?

Drivers License #

Copy of Insurance & Registration

Upload File

Age

Are you 18 or older?

U.S.A. Visa Status

Previously Employed by Us?*

If Yes, When?

Criminal Background*

Case

Ever convicted of a felony?

If Yes, Please Explain

How Did You Hear About This Job?*

Work Shift Desired*

Work Hours Desired*

Available Start Date?*

Desired Salary*

Are you ineligible to be employed with a North Carolina licensed health care entity as a result of being found guilty by a court of law for abusing, neglecting, or mistreating individuals in a health care related setting?

Are you able to perform all of the duties required by the position for which you are applying, without endangering yourself or compromising the safety, health, or welfare of the Residents/Clients or other Staff Persons?*

Yes

If No, Please Explain

Highest Level of Education?*

When Did You Graduate?*

License / Certification Number

List any special skills or qualifications which you possess and feel are relevant to health care and the position for which you are applying.*

Employment History

Employment History

Employer 1

Employer 1

Company Name

Address

City

State

Zip Code

Phone

May We Contact This Employer?

Start Date

End Date

Supervisor Name

Reason for Leaving?

Position and Responsibility?

Starting Pay

Ending Pay

Employer 2

Employer 2

Address

City

State

Zip Code

Phone

May We Contact This Employer?

Start Date

End Date

Supervisor Name

Reason for Leaving?

Position and Responsibility?

Starting Pay

Ending Pay

Employer 3

Employer 3

Company Name

Address

City

State

Zip Code

Phone

May We Contact This Employer?

Start Date

End Date

Supervisor Name

Reason for Leaving?

Position and Responsibility?

Starting Pay

Ending Pay

Military Service

Check box if you were you in the military.

Special Training

Check if you received any special training.

If Your Received Special Training, Explain

References

References

Reference Name

Relationship

Phone

Address

City

State

Zip Code

Reference Name

Relationship

Phone

Address

City

State

Zip Code

Reference Name

Relationship

Phone

Address

City

State

Zip Code

CPR/First Aid (If current)

TB Test

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Contact Information

Address: 3729 West Wilson St, Suite 7 Farmville, NC 27828

Mailing Address: P.O. Box 577 Farmville, NC 27828

Phone: (252) 228-8306

Fax: (252) 228-0012

Email: aspecialplacehomecare@gmail.com

Monday - Friday : 9:00 am - 4:30 pm

Saturday - Sunday: Closed

After Hours Available