Employment Application Form

Please read carefully before completing this form.

All information provided on this application must be true, complete, and accurate to the best of your knowledge. Any false, misleading, or omitted information—whether discovered before or after employment—may result in disqualification from consideration or immediate termination. All sections must be completed in full. If a question does not apply, please write “N/A.”

Section 1: Applicant Information

Full Name

Date of Birth

Social Security Number (Last 4 digits)

Current Address

City

State

Zip Code

Phone Number

Email Address

Emergency Contact Person

Relationship

Emergency Contact Phone

Section 2: Position Desired

Position Applying For:

Other

Employment Type

Do you have reliable transportation to client homes?

Are you available to work

Are you authorized to work in the United States?

Section 3: Education and Training

Name of School

Name of College

Name of Technical

Location (City/State)

Location 1

Location 2

Location 3

Major / Program

Program 1

Graduation Year

Grad Year 1

Relevant Certifications (check all that apply)

Date of Last TB Screening

Other

Results

Section 4: Work Experience

List your most recent employers (starting with the current or last one).

Employer Name

Name

Position / Title

Title 1

Title 2

Title 3

Title 4

Title 3

Dates Employed

Dates 1

Dates 2

Dates 4

Dates 3

Dates 5

Supervisor Name

Supervisor Name 1

Supervisor Name 2

Supervisor Name 3

Supervisor Name 4

Supervisor Name 5

Supervisor Contact

Phone 1

Reason for Leaving

Reason For Leaving 1

Section 5: Professional References

Provide three (3) professional references who can verify your work performance or character.

Name

Relationship

Relationship 1

Phone Number

Email

Address

Address 1

Section 6: Background & Screening Information

As required by 12VAC5-381-410 and Code of Virginia §32.1-162.9:1, all employees must pass background checks and meet health/safety criteria.

Have you ever been convicted of, or pleaded guilty to, any criminal offense (including misdemeanors and felonies)?

Yes

Explain

Have you ever been found guilty of abuse, neglect, or exploitation of a child or vulnerable adult?

Yes

Do you consent to a Virginia State Police Criminal History and Central Registry background check?

Yes

Driver’s License Number

State

Expiration Date

Do you carry current automobile insurance (if job duties require transportation)?

Yes

Not Applicable

Section 7: Physical and Health Information

In compliance with 12VAC5-381-410 and OSHA regulations, all employees must be physically able to perform essential job functions.

Can you perform the essential duties of this position with or without reasonable accommodation?

Yes

Have you had a physical examination or health screening within the past year?

Yes

Date

Have you been tested for tuberculosis (TB) within the last 12 months?

Yes

Scheduled

Do you have any conditions that may affect your ability to safely care for clients?

Yes

Please Explain

Section 8: Skills and Competency Checklist

Please check all areas in which you have experience or competency:

Personal Care Tasks

Client Support

Household Assistance

Specialized Training or Experience

Section 9: Acknowledgments and Agreements

Please read and initial each statement:

Checkbox Field

I understand that all employment offers are contingent upon successful completion of required background checks, reference verification, and health screenings as required by 12VAC5-381-410.

I understand that falsification, omission, or misrepresentation of information may result in dismissal or denial of employment.

I agree to comply with all agency policies, including confidentiality, HIPAA compliance, infection control, and professional conduct.

I understand that employment is at-will and may be terminated by either party at any time, consistent with Virginia employment law.

I authorize the agency to verify all information provided in this application, including contacting previous employers and references.

Applicant Certification and Signature

I certify that all information provided on this application is true and complete to the best of my knowledge. I understand that false or misleading statements shall be grounds for rejection of my application or immediate dismissal if employed.

Applicant’s Signature

Sign Here

Date

Attachments Required

Checkbox Field

Resume or work history summary

Copy of PCA certificate or equivalent training

Valid photo ID and Social Security verification

Proof of TB screening / health statement

CPR / First Aid certificate (if applicable)

Copy of driver’s license and insurance (if applicable)

Signed confidentiality and HIPAA agreement

Background check consent form

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