Caregiver Job Application - Serenecare Inc.

Personal Information

Click to upload
Passport Photo

Photo Requirements

Recent passport-style photo
Clear face visibility
Plain background preferred
Maximum file size: 2MB
Formats: JPG, PNG, JPEG

Full Name *

Phone Number *

Email Address *

Date of Birth *

Social Security Number *

Address *

Position Details

Position Applying For *

Caregiver CNA HHA Nurse

Availability *

Full-Time Part-Time Per Diem

Available Start Date *

Qualifications

Are you Licensed/Certified? *

Yes No

Certification Type

Years of Experience *

Skills (Check all that apply)

Personal Care Companionship Meal Prep Mobility Assistance Dementia Care Medication Mgmt Wound Care Vital Signs

Background Information

Are you authorized to work in the United States? *

Yes No

Do you have a criminal record? *

Yes No

Proof of Lawful Status (ID, Passport, or Work Permit) * Upload a clear copy of your ID, Passport, or Work Authorization document (JPG, PNG, or PDF)

Banking Information (For Direct Deposit)

Bank Routing Number *

Bank Account Number *

Your banking information is kept secure and confidential for payroll purposes only.

References

Reference Name *

Reference Phone *

Signature & Declaration

I confirm that the information provided above is accurate and complete to the best of my knowledge. I understand that any false statements or omissions may result in disqualification from employment or termination if discovered after hiring.

Your Signature *

Date *