Franchise 548 Application Form

Application 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.

Office Location

Select Office Location

Personal Information

First Name *

Last Name *

Social Security Number *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number *

Section 1 - Position

Which position are you applying for? (required)

Do you have experience in this position? (required)

Yes No

How did you hear about this position? (required)

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Section 2 - Experience

Have you been a caregiver in a home before? (required)

Yes No

If not, have you worked as any type of caregiver before?

Yes No

Are you currently employed? (required)

Yes No

Section 3 - Background check

Are you prepared to take the state required background check, fingerprinting and drug screen? (required)

Yes No

Section 4 - Availability

How many hours do you expect to work each week? (required)

(Numeric Answer Only)

What hours are you available on Monday? (required)

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What hours are you available on Tuesday? (required)

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What hours are you available on Wednesday? (required)

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What hours are you available for on Thursday? (required)

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What hours are you available on Friday? (required)

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What hours are you available on Saturday? Two weekends a month required. (required)

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What hours are you available on Sunday? Two weekends a month required. (required)

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Section 5 - Credentials

Have you taken the PCA class? (required)

Yes No

Are you a CNA? (required)

Yes No

Did you have similar certification in a different state? (required)

Yes No

Do you have current CPR/First Aide? (required)

Yes No

Do you have current TB test? (required)

Yes No

Do you have valid Georgia Drivers License? (required)

Yes No

Do you have current auto insurance? (required)

Yes No

Section 6 - Referrences

Please list at least 3 references and their contact #. Only 1 may be a family member. (required)

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Section 7 - Job History

Please list last 10 years of work history (required)

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Section 8 - Emergency Contact

In the case if an emergency, who would you like us to contact. Please list name, relation and contact phone number. (required)

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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.

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