Personal Care Assistant Application

Application Terms & Conditions

Applicant Information

Conviction will not necessarily be a bar to employment. Each instance will be considered in relation to the position for which you are applying.

What schedule can you work?

What is the earliest that you can go into work and what is the latest you can stay? This will help us in locating a client with hours you can work.

Employment History

Provide the following information for your past four (4) employers, assignments or volunteer activities, STARTING with the most recent.


Please provide three references, other than family members.

Skills & Qualifications

Summarize any training, skills, licenses, and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.

Educational Background


I understand that if I am employed, any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer's service whenever it is discovered.

I give the employer the right to contact and obtain information from all references, employers, and educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from all liability the employer and it's representatives for seeking, gathering and using such information and all other persons, corporations and organizations for furnishing such information.

The employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state or federal law.

This application is current for only 60 days. At the conclusion of this time, if you have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

The employer reserves the right to terminate my employment at any time, with or without cause and without prior notice except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of the employer other than an authorized officer has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer.

I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.

I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.

Note: Review the entire form to be sure no questions have been omitted if required. 

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