Apply for Caregiver Application

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:Caregiver Application
ID:GH - Michigan
Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
* Social Security Number:
* Date of Birth:
Personal Information
* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment)
Yes
No
* Are you at least 18 years or older? (If no, you may be required to provide authorization to work)
Yes
No
* Have you ever worked for this Company before?
Yes
No
* Do you plan to bring a client with you?
Yes
No
Upload Identification
If you do not upload this information it will delay the hiring process.

Acceptable forms of identification include:
• Passport or Passport Card
• Permanent Resident Card
• State issued Driver's License or ID
• School ID (with a photo and valid school year)
• Voters Registration Card
• Military ID

* UPLOAD A PHOTO OF YOUR IDENTIFICATION
Employment History

Employer 1

Job Title
From
To
Company Name
Contact Information (Phone number, address, or email)
May we contact?
Yes
No
Reason for leaving
Education

School 1

Name
Location
Did you Graduate?
Yes
No
Degree Received
Subjects Studied/Major
References

Please provide a reference that is not a relative.

Name
Relationship
Phone Number
Email
TB Testing Requirements
You may submit existing TB Test Results OR we can submit a request for you to take a new test.
* Do you have TB Test Results already?
Yes
No

If yes, you may submit prior test results if they meet the following criteria:
• Must be within the last 11 months.
• Must be a 2-Step Skin Test OR Blood Test.
• If it shows a positive result, the accompanying Chest X-Ray must be included.
• Results must include the caregiver’s full name, date of test, and the test result (positive or negative).
• Screenshots are accepted if all required elements are clearly visible.

UPLOAD TB RESULTS

If the results do not meet our requirements, you will be asked to upload additional documentation OR take a new TB Test.

Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Do you have a disability that would require special accommodations at work?
Yes
No
I Choose Not to Respond
Race/Ethnicity:
American Indian or Alaska Native
Black or African American
Hispanic or Latino
Asian
White (Not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander
Two or More Races
I Choose Not to Respond
Have you ever served in the military? (Please check all that apply)
Yes
No
I Choose Not to Respond

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