Date: 4/24/2014

Application Form

Franchise 832

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Personal Information

First Name * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License #
Mobile Phone
Email *

Section 1 - Personal Information

Number Question Effective Date Expiration Date
1.0 Date of Application  
     
2.0 Name: (Last, First, Middle) (required)  
     
3.0 Email Address  
     
4.1 Current Street Address (required)  
     
4.2 City (required)  
     
4.3 State (required)  
     
4.4 Zip Code (required)  
     
4.5 Have you been a continuous resident of North Carolina for 5 years or more? (required)  
     
5.0 Home Phone Number: (required)  
     
6.0 Cell Phone Number:  
     
7.0 Work Phone Number:  
     
8.0 Best time to call you:  
     

Section 2 - General Background Information

Number Question Effective Date Expiration Date
1.0 Do you have a high school diploma? (required)  
     
2.0 Do you have a valid driver's license? (required)  
     
3.0 Do you have reliable transportation? (required)  
     
4.0 We do multiple background checks. Have you ever been convicted of a crime? (required)  
     
4.1 If yes, please explain.  
 

Section 3 - Employment Information

Number Question Effective Date Expiration Date
1 Are you currently employed?  
     
2 Please list your most recent job and dates employed. (required)  
 
3 If you are currently employed, please explain reason for looking for more work.  
 
4 Please describe your employment for the last 10 years (location, duties, time employed.)  
 

Section 4 - Caregiving Experience

Number Question Effective Date Expiration Date
1 Are you currently a CNA? (required)  
     
2 Please describe any experience in caregiving for seniors.  
 

Section 5 - Availability

Number Question Effective Date Expiration Date
1 How many hours per week are you interested in working? (required)  
     
2 What days and hours are you available to work? (required)  
     
3 Are you available to do overnight shifts?  
     
4 Are you available to do live in shifts?  
     

Section 6 - Interest

Number Question Effective Date Expiration Date
1 Why are you interested in becoming a caregiver? (required)  
 

Section 7 - Applicants Certification and Agreement

Number Question Effective Date Expiration Date
1 I certify that information contained in this application is true and complete. I understand that false information may be grounds for not being hired or for immediate termination of employment at any point in the future if I am hired. (required)  
     
2 I authorize the verification of any or all information listed above. (required)  
     



I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.