Application Form

Company
This field is for validation purposes and should be left unchanged.
Position(s) Applying For:*
- In-Home Aide
- Companion
- CNA
How Did You Hear About The Position
- Newspaper
- Friend
- Relative
- Employment Agency
- Job Finder
- Internet Search
- Home Loving Employee
- Walk-in
- Facebook
- Other
Name*
First Middle Last
Address*
Street Address City State ZIP Code
Home Phone*
Cell Phone
Email*
Enter Email Confirm Email

Educational Experience
Name of High School
Location (Complete Mailing Address)
Number Of years Completed?
Major & Degree?
Name of College
Location (Complete Mailing Address)
Number Of years Completed?
Major & Degree?
Name of Graduate School
Location (Complete Mailing Address)
Number Of years Completed?
Major & Degree?
Bus. or Trade School
Location (Complete Mailing Address)
Number Of years Completed?
Major & Degree?
Name of Professional School
Location (Complete Mailing Address)
Number Of years Completed?
Major & Degree?
Special Honors
Do you have a high school diploma/GED?*
- Yes
- No
Please indicate highest level completed*
- Some College
- Associate Degree
- Bachelor's Degree
- Graduate or Professional Degree
- Other
Military
Are you a veteran of the United States military service?*
- Yes
- No
If yes, what branch?
If yes, date entered military
Month
Day
Year
Date discharged?
Month
Day
Year
Please list other special skills you may have in reference to Elder Care (e.g. Alzheimers or dementia), fluency in other languages, licenses, special training required for the position for which you are applying.

Work Experience
Employer Name
Location (City, State)
Job Title
Work Performed
Start Date
Month
Day
Year
End Date
Month
Day
Year
Reason for Leaving
Employer Name
Location (City, State)
Job Title
Work Performed
Start Date
Month
Day
Year
End Date
Month
Day
Year
Reason for Leaving
Employer Name
Location (City, State)
Job Title
Work Performed
Start Date
Month
Day
Year
End Date
Month
Day
Year
Reason for Leaving
References
Please list two references other than relatives or previous employers
Name*
Position
Address
Phone*
Company
Name*
Position
Company
Address
Phone*
Optional: Upload Your Resume
Accepted file types: doc, docx, pdf, Max. file size: 100 MB.

allowed file types .DOC .DOCX .PDF

WAIVERS AND DISCLOSURES

Please read each section carefully and sign where indicated.

AT-WILL EMPLOYMENT
It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or a promise of future benefits by this agency. I understand and agree that, if hired; my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either myself or my employer. I also understand that this written statement supersedes any and all oral representations made by agents or representatives of this agency.
CERTIFICATION OF TRUTH AND ACCURACY
I certify that the information in this application is true, complete and correct. I understand that false answers,, statements, or significant omissions made by me on this form shall be sufficient cause for denial of employment or discharge..
NOTIFICATION AND AUTHORIZATION TO REQUIRE A MEDICAL EXAMINATION
I hereby certify that, if hired, I will disclose any limitations I have that may impact my ability to do the job. I understand that I may also be required to undergo a pre-employment or post-employment medical exam by Home Loving Care designated Health practitioner.
NOTIFICATION AND AUTHORIZATION TO CONDUCT BACKGROUND INVESTIGATION
I understand that I may be subject to a background check, and hereby authorize North Carolina Special Investigative Services, as an Agent for Home Loving Care to investigate my background to determine any and all information of concern as to my record, whether same is of record or not, and I release employers and persons named in my application from all liability for any damages on account of his/her furnishing said information. Additionally, you are hereby authorized to make any investigation of my personal history, educational background, military record, motor vehicle records, and criminal records of your choice. I authorize the release of this information by the appropriate agencies to the investigating service. This authorization, in original or copy form, shall be valid for this and for any future reports and updates that may be required. I understand that passing the background check is a condition of employment. A negative background check can be grounds for dismissal, even if an offer has been made to me and I have been hired. The background check fee is non-refundable.
Consent*
I have read the above and Agree!
Signature*

Reference Checking Consent and Authorization Form

Disclosure

Please read the information on this form carefully and completely.

I have applied for employment with Home Loving Care and have provided information about my previous employment. I authorize Home Loving Care to conduct a reference check with my present and /or previous employer(s). I understand that reference information may include, but not be limited to, verbal and written inquires or information about my employment performance, professional demeanor, rehire potential, dates of employment, and employment history.

My signature below authorizes my former or current employers and references to release information regarding my employment record with their organizations and to provide any additional information that may be necessary for my application for employment with Home Loving Care, whether the information is positive or negative. I knowingly and voluntarily release all former and current employers, references, and Home Loving Care form any and all liability arising from their giving or receiving information about employment history, my academic credentials or qualifications, and my suitability for employment with Home Loving Care.

I further authorize Home Loving Care to obtain feedback and references from my supervisors over the course of my employment with Home Loving Care. I understand that subsequent and continued employment with Home Loving Care may be subject to this feedback.

This form may be photocopied or reproduced as a facsimile, and these copies will be as effective as a release or consent as the original which I sign.
Consent*
I understand and agree to the above!
Signature*

DRIVER's DISCLOSURE FORM

.

.

DEPARTMENT OF TRANSPORTATION

DIVISION OF MOTOR VEHICLES

TRAFFIC RECORDS SECTION

3105 MAIL SERVICE CENTER

RALEIGH, NC 27699-3105 .

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. Effective September 13, 1997, all motor vehicle records are subject to the Federal Driver's Privacy Protection Act (FDPPA) and General Statue 20-43.1. The FDPPA and Gs 20-43.1 require that personal information in the Division of Motor Vehicles records be closed to the public. Personal information from these records may be released to individuals or organizations that qualify under one of the fourteen (14) listed on the back of this form. These exceptions are summarized statements of permissible uses. .

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By signing this form, you are granting the company access to your personal information under exception number 13 of the FDPPA and GS 20-43.1

NAME OF COMPANY/AGENCY Home Loving Care
Name of Driver*
DL no*
State of DL*
State
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Consent*
I agree to providing my consent.
Signature*

Nationwide Background Records Request

NCSIS North Carolina Special Investigative Services

3607 Cotswold Terrace

Greensboro, NC 27455

336-288-8083/336-508-8601

Email your request to: NCSIS@yahoo.com
Home Loving Care has requested a Nationwide Background Record on:

Applicant Name: (Include all maiden names & other names used)
Name*
First Middle Last
Name
First Middle Last
Name
First Middle Last
Social Security Number
Date of Birth*
MM slash DD slash YYYY
Signature*

Step 1 of 8

Applicant Details

Driver's License/Background History

Employment Details

Educational Experience

Military

Work Experience

References

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