Providing Long Term Care
Insurance, Private Pay & Medicaid Personal Care Services

Your Trusted Source for Supervised in Home Care Since 1997

800-624-9194 Central/Southside, VA

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Electronic Employment Application

Thank you for your interest in Caremed Inc.! Please complete the application below. We will contact you within 48 business hours.

Please click each box to indicate that you have read the following information before completing the application:

I am not guaranteed a job offer or job interview by completing this application form

1. I am not guaranteed a job offer or job interview by completing this application form.

2. This application form must be filled out in its entirety in order for it to be considered for employment.

3. If the information I’ve provided on this application cannot be satisfactorily verified, my application may be considered as incomplete and deem me ineligible for a position with Caremed Inc.

4. Applications are filed according to job title. I understand that applying for "ANY POSITION" is not an acceptable response. I must include all positions I am applying for.

4.Applications are filed according to job title. I understand that applying for "ANY POSITION" is not an acceptable response. I must include all positions I am applying for.

5. Due to the large number of applications received and the competitive nature of the employment process, I understand Caremed Inc., will not release specific reasons for employment decisions unless required by law.

6. After completion of this application form and a successful interview process, I will be provided a conditional offer and will be subjected to the following background checks:

Employment Reference Check

Criminal Records Check

Applicant Details

Applicant Details

First Name

Last Name

Phone Number

May we contact you via text message?

Yes

Email Address

May we contact you via email?

Yes

Current Street Address

City

State

Zip code

Are you 18 years of age or older?

Yes

How did you hear about this position? (Please be as specific as possible. This helps our recruitment efforts.)

What date are you available to start work?

Resume

Resume

Upload Your Resume

Employment Status

Employment Status

For which position are you applying for?

Have you worked for Caremed Inc. before?

Yes

If yes, when?

Which job status would you prefer?

Full Time

Part Time

Temporary

Intern

What is your preferred rate of pay?

Are you able to perform the requirements of this job, with or without accommodations, based upon the criteria listed on the job advertisement?

Yes

Are you legally authorized to work in the United States?

Yes

Availability

Availability

Please mark X by your greatest shift preference. We understand that you may have more than one shift preference and will discuss more in the interview process.

First Shift

Second Shift

Third Shift (Overnights)

Are you available Saturdays?

Yes

If so, what shift?

Are you available Sundays?

Yes

If so, what shift?

Are you available to work overtime if required?

Yes

Do you have a reliable means of transportation?

Yes

Do you have a valid drivers’ license?

Yes

Would you prefer worksites near or on the bus line?

Yes

No preference

Are you interested in working in facility care?

Yes

No preference

If yes, what shift?

Are you willing to work with:

Enter your free text here

Pets

Yes

Children

Yes

Smokers

Yes

One patient

Yes

Float between patients

Yes

Employment

Employment

I have read and understood the following: My application may not be considered unless every question in this section is answered. Caremed Inc., will make every effort to contact my previous employers. I understand that the telephone numbers of the past employers listed will be considered correct. I will use Google or another internet search engine to verify information. For employers outside the U.S., I understand a correct phone number, fax number and email address are mandatory.

Are you currently working for this employer?

Yes

If yes, may we contact?

Yes

Company Name

Address

City

State

Phone

Fax or Email

Start of Employment

End of Employment

Job Title

Supervisor Name

Salary/Wage

Reason for Leaving

Previous Employer

Please provide your previous employer prior to your current position

Company Name

Address

City

State

Phone

Fax or Email

Start of Employment

End of Employment

Job Title

Supervisor Name

Salary/Wage

Reason for Leaving

May we contact this employer?

Yes

Previous Employer

Please provide your previous employer prior to your current position

Company Name

Address

City

State

Phone

Fax or Email

Start of Employment

End of Employment

Job Title

Supervisor Name

Salary/Wage

Reason for Leaving

May we contact this employer?

Yes

Specialized Experience

Specialized Experience

Do you speak a second language?

Yes

If yes, please note each language:

Level

Beginner

Intermediate

Proficient

Level

Beginner

Intermediate

Proficient

Check which valid license/certification you currently hold?

Enter your free text here

CNA

LPN

PCA

Other license

Are you CPR certified?

Please X your experience level by each category:

Enter your free text here

SKILL / ABILITY

SKILL / ABILITY

ALZHEIMERS PATIENT

NO EXPERIENCE

LIMITED (< 1 YR)

ADVANCED (> 1 YR)

BED BATH

NO EXPERIENCE

LIMITED (< 1 YR)

ADVANCED (> 1 YR)

COMPANIONSHIP

NO EXPERIENCE

LIMITED (< 1 YR)

ADVANCED (> 1 YR)

COOKING

NO EXPERIENCE

LIMITED (< 1 YR)

ADVANCED (> 1 YR)

CPR

NO EXPERIENCE

LIMITED (< 1 YR)

ADVANCED (> 1 YR)

DEMENTIA

NO EXPERIENCE

LIMITED (< 1 YR)

ADVANCED (> 1 YR)

ELECTRONIC NOTES

NO EXPERIENCE

LIMITED (< 1 YR)

ADVANCED (> 1 YR)

HOYER LIFT

NO EXPERIENCE

LIMITED (< 1 YR)

ADVANCED (> 1 YR)

MEDICAID NOTES

NO EXPERIENCE

LIMITED (< 1 YR)

ADVANCED (> 1 YR)

MECH. EQUIP CARE

NO EXPERIENCE

LIMITED (< 1 YR)

ADVANCED (> 1 YR)

PATIENT TRANSFERS

NO EXPERIENCE

LIMITED (< 1 YR)

ADVANCED (> 1 YR)

PERSONAL HYGIENE (SHAVING/BEARDS/HAIR

NO EXPERIENCE

LIMITED (< 1 YR)

ADVANCED (> 1 YR)

SPECIALIZED DIET MEALS

NO EXPERIENCE

LIMITED (< 1 YR)

ADVANCED (> 1 YR)

STROKE

NO EXPERIENCE

LIMITED (< 1 YR)

ADVANCED (> 1 YR)

WALKER / WHEELCHAIR ASSISTANCE

NO EXPERIENCE

LIMITED (< 1 YR)

ADVANCED (> 1 YR)

List other specialized experience

Other specialized training relevant to the position applied for

Military Service

Military Service

Are you a veteran?

Yes

If yes, what branch?

Dates of Services

Rank at discharge

Type of discharge

If not honorable, please explain

Security

Security

Have you used any names other than the one given above? If so, please list below.

Yes

Have you been convicted of a felony? If so, please describe in the boxes below. (In accordance with company policy this information will be reviewed for job relatedness and time since last conviction. (Some convictions may not preclude you from employment with Caremed Inc.)

Yes

Have you ever been disciplined or fired?

Yes

If yes, by which employer and why?

Has your professional license ever been revoked or suspended?

Yes

If yes, please provide date and explanation.

Education

Education

Highest Grade Completed

Please enter the name that your school records are identified under, if different from your current name.

High School(s)

College(s)

Business School / Other

Certification and Release

Certification and Release

I certify that I have read and understood the applicant note at the top of this form. I also certify that all answers and statements given by me to the subsequent questions are complete and true to the best of my knowledge and belief.

understand that any false information, omissions or misrepresentations of facts on this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus to verify any of this information. I authorize all former employers, persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. Per company policy, I am willing to submit to a background investigation.

Electronic Signature

Date

Thank you for contacting us.
We will get back to you as soon as possible.

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