Apply Today Join the PrimeCare Nursing Team today! Step 1 of 10 10% Conditions of Employment Thank you for your interest in seeking employment with PrimeCare. In order to be considered for employment. You Must... Have a smartphone at all times to report in/out for work and to receive updated schedule information through apps and our web portal Submit to a criminal background record check Have your own dependable transportation Have proof of auto insurance and a current driver’s license Complete our in-house training program if you’re not a CNA Be able to read, write, speak and understand the English language and be able to accurately fill out the required daily paperwork Be physically able to perform some heavy lifting, stooping, & bending Agree to and pass random drug screenings before employment and at any time during employment If you are willing to meet the above requirements if offered employment, please sign below and continue on with the application process. Statement of Denial: I agree that by submitting this application, I am electronically signing the application. Agree Applicant Signature Date MM slash DD slash YYYY Application for Employment Instructions: Please answer all sections completely. Application will remain Active for 6 mos. Date of Application: MM slash DD slash YYYY Email Name: First Middle Initial Last SSN Current Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell Phone:Other PhonePosition Applying For: Personal Support Aide CNA Nurse (RN / LPN) Clerical Aide positions are considered part-time on an as needed basis. We do try however to give as many hours as we can based on our client needs. We do not guarantee a certain amount of hours. Are you seeking: Full time Part time PRN Date Available for Work: MM slash DD slash YYYY Have you ever been employed here before? Yes No If so, what dates and under what name? Did you work a notice when you left? Yes No If not, why? Do you have friends or family members currently employed with PrimeCare? Yes No If so, Who? Do you have friends or family members currently receiving services with PrimeCare? Yes No If so, who? Do you have a legal right to be employed in the U.S.? Yes No What other languages can you speak? Have you lived in any other states? Yes No If so, list states: Are you at least 18 years of age? Yes No Have you ever been convicted of a felony? Yes No Have you ever failed a work related drug test? Yes No Have you ever tested positive for TB? Yes No If yes, were chest x-rays taken? Yes No Certified Nursing Aide (CNA) Course: Do you have current CNA Certification? Yes No Are you certified in the state of Georgia? Yes No Certified in any other state(s)?: Name & location of CNA course: Did you graduate? Yes No What year? Educational History High School / GED Name of School, City, State Select Last Year Finished12th11th10th9thGraduated? Yes No GED Yes No Degree or Certificate College or Technical School Name of School, City, State Select Last Year Finished1234Graduated? Yes No Degree or Certificate Employment History Provide at least 5 years of employment history, including any periods of unemployment. Fill out completely Current or Most Recent Job Company (Current) From Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Address/State PhoneMay we contact them? Yes No Job Title Salary $: Last name while employed: Nature of Duties Immediate Supervisor Reason for Leaving: Did you work a notice? Yes No Explain any gaps in employment history between this job and your last job or comments: 1st Previous Job Company (Previous 1) From Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Address/State PhoneMay we contact them? Yes No Job Title Salary $: Last name while employed: Nature of Duties Immediate Supervisor Reason for Leaving: Did you work a notice? Yes No Explain any gaps in employment history between this job and your last job or comments: 2nd Previous Job Company (Previous 2) From Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Address/State PhoneMay we contact them? Yes No Job Title Salary $: Last name while employed: Nature of Duties Immediate Supervisor Reason for Leaving: Did you work a notice? Yes No Explain any gaps in employment history between this job and your last job or comments: 3rd Previous Job Company (Previous 3) From Date MM slash DD slash YYYY To Date MM slash DD slash YYYY Address/State PhoneMay we contact them? Yes No Job Title Salary $: Last name while employed: Nature of Duties Immediate Supervisor Reason for Leaving: Did you work a notice? Yes No Explain any gaps in employment history between this job and your last job or comments: Professional / Personal References Give at least two references who have knowledge of your work. (other than relatives) Reference 1 Name (Reference 1) First Last Position Address (include City/State) Phone - Work / HomeYears Known Reference 2 Name (Reference 2) First Last Position Address (include City/State) Phone - Work / HomeYears Known Reference 3 Name (Reference 3) First Last Position Address (include City/State) Phone - Work / HomeYears Known Reference 4 Name (Reference 4) First Last Position Address (include City/State) Phone - Work / HomeYears Known Certification of Applicant By signing my name verified by PrimeCare, should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that PrimeCare is relieved of all commitments, financial or otherwise to unemployment, and that I am subject to immediate discharge without recourse. I understand and agree that any employee hand book which I may receive will not constitute an employment contract, but will be merely a gratuitous statement of PrimeCare Policies. All field aides are hired as part-time employees. Scheduled number of hours may vary week to week due to client case load. I understand that PrimeCare reserves the right to require its employees to submit to blood tests or urinalyses for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought into or taken out of the PrimeCare office. I understand that refusal to submit to a urinalysis, blood test or search, when requested to do so, may result in termination of my employment. Compliance with PrimeCare’s Substance Abuse Policy is a condition of employment. We require that every newly hired employee be free of alcohol or drug abuse. Each offer of employment is contingent upon successfully completely a urinalysis test/screen for alcohol and drugs in accordance with PrimeCare’s policy. Release: I hereby authorize any prior employers to provide such information concerning my employment history with them as may be requested and also authorize the Registrar / Placement Office of all educational institutions attended to release an official copy of my transcript. I also authorize any appropriate licensing board to release full information concerning my licensure status and my licensure history. Below, I certify that the information in this application is true and complete for all practical purposes. Statment of Denial: I certify that I have never been shown by any credible evidence (e.g. a court or jury, a department investigation, or other reliable evidence) to have abused, neglected, sexually assaulted, exploited, or deprived any person or to have subjected any person to serious injury as a result of my intentional or grossly negligent misconduct. Please Initial Below I understand that any employment relationship with this employer is “at will”, which means that the employee may resign at any time and the employer may discharge the employee at any time with or without cause. I have read all of the above and understand these conditions of employment. Applicant Signature Date MM slash DD slash YYYY Authorizaion to Release Information To Be Completed by: Job Applicant I, (Name) authorize the investigation of all matters contained in my employment application and hereby give PrimeCare Nursing Services, Inc. permission to contact schools, previous employers, references, and others. I hereby release PrimeCare Nursing Services, Inc. and its representatives from any liability for seeking and relying on such information and all other persons, corporations or organizations for furnishing such information. You have my authorized consent to release pertinent information regarding my previous employment for the purpose of a reference. Applicant Name (PRINT) Maiden Name: S.S. Applicant Signature: Date MM slash DD slash YYYY Application Attachment Please fill this form out completely. If you are hired, this form becomes part of the schedule building process and is removed from the application. Personal Name First Last County Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Cell Phone #:Other #:Email Work Area If accepted for employment, I will work in the following counties: Check as many as apply. Work Area BARTOW CARROLL CATOOSA CHATTOOGA CHEROKEE COBB DADE FANNIN FLOYD GILMER GORDON HARALSON MURRAY PAULDING PICKENS POLK WHITFIELD Availability Please fill in the earliest available start time for each day and the time you must be off each day. If there is a day you are not available at all, please check the “Not Available” box. Monday: Available Start Time Monday: End Time Monday Not Available Tuesday: Available Start Time Tuesday: End Time Tuesday Not Available Wednesday: Available Start Time Wednesday: End Time Wednesday Not Available Thursday: Available Start Time Thursday: End Time Thursday Not Available Friday: Available Start Time Friday: End Time Friday Not Available Saturday: Available Start Time Saturday: End Time Saturday Not Available Sunday: Available Start Time Sunday: End Time Sunday Not Available What is the number of hours you desire each week? What is the minimum number of hours you must have each week? Are there any restrictions as to the days and hours you cannot work? YES NO Please explain: Are you allergic to animals or cigarette smoke? Please explain: YES NO Please explain: Do you smoke? YES NO Please list any dates within your first 90-days of employment that you will need off for medical appointments, vacation, etc. Medical appointments, vacation, etc. Background Check* I Agree to a Background Check For this type of employment, state law requires a national and state background check as a condition of employment. by checking the button above, you are agreeing to a background check.Signature: Date MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Δ This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
