315 530 3023

Follow Your Passion

Peace at Homecare is always looking for compassionate caregivers to join our team

Our Values

Build positive life experiences

Deliver exceptional care with a tender heart

Restore peace to our

client's life

Apply to Caregiver Position

Date of Application *

How Did You Learn About Us or Who Referred You? *

First Name *

Middle Name

Last Name *

Phone Number *

Email *

Current Address

Street *

City *

State *

Zip *

Mailing Address (If Different)

Street

City

State

Zip

Are You 18 Years or Older?

YesNo

Do You Have a Valid Driver's License?

YesNo

Are You Able to Use Your Own Car? *

YesNo

Are you able to use your own car to transport clients? *

YesNo

Are you a U.S. citizen or approved to work in the United States? *

YesNo

Do you have any reservations about working around cats, dogs, or other pets? *

YesNo

Date You Can Start *

Are you employed now? *

YesNo

Have You ever been convicted of a criminal offense (felony or misdemeanor)? *

YesNo

If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:

What hours/days are you available to work? *

Can you work overnight shifts? *

YesNo

Can you work weekends? *

YesNo

Education/Special Training

Name of High School: *

Highest grade completed:

GED:

College:

Degree:

Certifications you have:

PCACNAHHALPN

Other:

Please describe any experience you have that may be applicable to the job you are applying for: *

Current and Past Employment (Please List Your Last Three Employers)

Employer 1

Employer's Name: *

Date employment began: *

Date employment Ended: *

Supervisor’s Name/Phone Number: *

Reason for Leaving: *

Employer 2

Employer's Name: *

Date employment began: *

Date employment Ended: *

Supervisor’s Name/Phone Number: *

Reason for Leaving: *

Employer 3

Employer's Name: *

Date employment began: *

Date employment Ended: *

Supervisor’s Name/Phone Number: *

Reason for Leaving: *

Please Give Two PROFESSIONAL References, Not a Friend or Relative:

Reference 1

Name: *

Business: *

Phone Number: *

Years Acquainted: *

Reference 2

Name: *

Business: *

Phone Number: *

Years Acquainted: *

Emergency Contact

Name: *

Relationship: *

Phone Number: *

“I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform to the company’s rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company’s option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company. I understand that no company representative, other than it’s president, and then only when in writing and signed by the president, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.”

Check this box to confirm the above certification:

I agree

Date *

We are an Equal Opportunity Employer. We consider all applications for all positions without regard to race, color, religion, gender, national origin, age, sexual orientation, genetic predisposition or carrier status, disability, marital status, pregnancy, veteran status, or any other legally protected class or status. Please notify a company representative if you require reasonable accommodation to participate in the application and/or interviewing process.

Applicant Signature (Type Full Name) *

PEACE AT HOMECARE IS A CONCIERGE, BOUTIQUE-STYLE COMPANION HOMECARE AGENCY AND A LICENSED AND BONDED CAREGIVER EMPLOYMENT AGENCY.