ALTC Caregiver Application

Applicant Information
Legal Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Current Address*

Street Address

Street Address Line 2

CityState

Zip Code

Additional Information*

	Yes	No
Are you 18 years of age or older?
Have you ever been employed by A Long Term Companion?
Are you legally authorized for employment in the US?
If hired, could you submit documentation verifying your identity and legal eligibility to work in the US?
Do you have a Driver's License?

Do you have a current 2-step PPD result? (Within the last 12 months)*

YesNo
Do you have a current Chest X-Ray or Quantiferon Gold Test result? (Within the last 36 months)*

YesNo
Have you lived in any other state(s) in the past 2 years?*

YesNo

Education, Licenses and Certifications

Education*

	Type of School	School Name	Degree	Graduated
1
2
3
4
5
6

Licenses and Certifications: Please enter information for your licenses or certifications. Abbreviations below: HHA - Home Health Aid, LPN - Licensed Practical Nurse, CHHA - NJ Certified HHA, RN - Registered Nurse, CNA - Certified Nurse Aide

	Type	License #	Expiration	Issued By	State
1
2
3
4
5

Employment Record
How much experience have you had in a formal (paid) caregiver position?*

No experienceLess than 1 yearBetween 1 and 3 yearsBetween 3 and 5 yearsMore than 5 years
Please give accurate and complete information for each of your 5 latest employers (agencies, institutions, patients, etc.). Include current employer(s), if any.

Add Employers
Employer 1*
Employer 2
Employer 3
Employer 4
Employer 5

References
List three persons who have knowledge of your work experience, qualifications, and/or education: current employer, past employers, supervisors, teachers, etc.(other than relatives or personal friends).
Reference 1*
Reference 2*
Reference 3*

Additional Information
How did you hear about us?

Company websiteInternet/Job BoardEmployee ReferralWalk-inOther
What is the best time for us to call you for a 15 min screening?*
EQUAL EMPLOYMENT OPPORTUNITY/DISCLAIMER *
Your Signature*

Clear
Contact Type (Hubspot)
Lead Status (Hubspot)
Should be Empty:

	Morning	Afternoon	Overnight	Not Available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Applicant Information

Education, Licenses and Certifications

Employment Record

References

Work Preferences

Additional Information