Job Pre Screen Form

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.

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* Required information.
Select Office Location *
Name *
Address *
City, State, Zip *
Phone * You must have a cell or home phone
Email Address *
Position(s) you are applying for * Hold the Ctrl key on your keyboard to select multiple choices
Do you have a valid Driver's License? *
Do you have your own safe and reliable vehicle to get you to and from a client's home *
How did you hear about us? *
We provide service to our clients 24 hours a day, 7 days a week, knowing that, what specific days and hours are you available to work? * Be specific!
Are you experienced, and what kind of experience do you have * Be specific!
Will you agree to a background check? * I understand that I will prepay $25 for a multi-state criminal background check. If approved by the management, $20 will be taken from the first paycheck. The background check is mine to keep although the agency must keep a copy.
When can you start work? * Date format: yyyy-mm-dd Use the calendar icon for easy date selection
Will you agree to a pre-employment drug screen, and have continued random drug tests? *
Are you eligible to work in the United States? * Proof of eligibility will be required before you can be employed.
Is your CPR certification current? *
Is your TB card current? *
CNA's - Are you currently listed on the N.C. Healthcare Personnel Registry? Only for Certified Nursing Assistants
Attach your resume, if you have one Select a file on your computer to attach to this form. Acceptable formats: .doc, .pdf, .txt


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