Caregiver Applicant Form

Personal Information

* First Name

*Last Name

* Email

* Address Line 1

Address Line 2

* Country

* State/Province

* City

* Zip/Postal Code

*Gender

* Mobile Phone

* Home Phone

*Date of Birth

* SSN

Educational Background New Educational Background

School/College/University

Qualification

Attach Document

Certifications

Background Check

Browse

CNA

Browse

PCA

Browse

TB Test

Browse

Employment History New Employment History

Please provide your latest employer information below.

Employer Name

Phone Number

Address

Country

State/Province

City

Zip/Postal Code

Served From

Served To

Position Held

Attach Document

References New Reference

Name

Phone Number

Miscellaneous Questions

Q.) Type of Employment Desired?

Q.) Position Desired?

Q.) Do you have reliable transportation to and from work?

Q.) Do you have the legal right to obtain employment in the United States?

Q.) Have you ever worked for Good Times Home Health Care, Inc.?

Q.) Have you ever been convicted of any of the following: a. felonies related to manufacture, distribution, prescription or dispensing of a controlled substance; b. felony health care fraud; c. felony for abuse, neglect, assault, battery, criminal sexual conduct (1st, 2nd or 3rd degree), fraud or theft against a minor or vulnerable adult; d. felony or misdemeanor patient abuse; e. felony or misdemeanor involving cruelty or torture; f. misdemeanor healthcare fraud; g. misdemeanor for abuse, neglect, or exploitation listed with the NC Health Care Registry; or h. any substantiated allegation listed with the NC Health Care Registry that would prohibit an individual from working in the healthcare field in the state of NC.? If yes, explain? [Please enter N/A in Additional Comments]

Yes

Caregiver Application Form

Personal Information

Educational Background New Educational Background

Certifications

Employment History New Employment History

Skills/ Preferences

References New Reference

Miscellaneous Questions

* Caregiver Signature