Join Our Team
and make a difference

Our agency strives to make a difference in our Community by allowing our Services and Care to make an impact in the lives of our clients that results in a healthier, independent and positive lifestyle change.

Thank you for your interest in working for our agency. Please submit the application below to be considered for a position as a health care provider.

We are currently looking for:

PCA (Personal Care Aide)

CNA (Certified Nursing Aide)

Please complete the below three forms for employment consideration: Application, Sworn Statement Or Affirmation and Permission To Make Inquiries

APPLICATION

Sworn Statement Or Affirmation

SWORN STATEMENT OR AFFIRMATION / APPLICANTS FOR LICENSED HOME CARE ORGANIZATION

To the Applicant: Section 32.1-162.9-1 of the code of Virginia requires that any applicant for employment with licensed home care organization provide the Commissioner's representative with a sworn statement or affirmation disclosing (1) whether the applicant has a criminal conviction or is the subject or any pending criminal charges within or outside the commonwealth of Virginia, and (2) whether the applicant has been subject of a founded complaint of child abuse neglect within or outside the commonwealth of Virginia. Any person making a materially false statement on this form shall be guilty of a class 1 misdemeanor. Further dissemination of the information provided on this form is prohibited other than to the Commissioner's representative or a federal or state authority or court as required to comply with an express requirement of law such further dissemination.

1. Name

Social Security Number

Address

2. Have you ever been convicted of a crime within or outside Virginia (but excluding offense committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law)? Check Box Yes

Yes

If Yes, List all and explain.

3. Are you the subject of any pending criminal charges within or outside Virginia? Check Box if Yes:

Yes

If Yes, List all and explain.

4. Have your ever been the Subject of a founded complaint of child abuse or neglect within or outside Virginia? Check Box if Yes:

Yes

If Yes, List and explain.

5. I hereby affirm that the information provided on this form is true and complete. I understand that the information is subject to verification. Check Box if Yes:

Yes

Applicant's Signature

Date

Permission To Make Inquiries

To Whom it May Concern

Last 4 of Social Security Number

I am seeking employment with Caregivers In-Home Care, LLC. I have given Caregivers In-Home Care permission to make inquiries of my work history with your company. I hereby release employers, schools, other persons, institutions or businesses from all liability in responding to inquires in connection with my application. I understand that false or misleading information given in my application or during the interview process may result in a refusal to hire or discharge in the event of employment. Please complete and I would like to thank you in advance for your cooperation regarding this matter. Check box below to indicate you agree.

Check box to agree

Applicants Name