Skip to content
Lithia Springs, GA , 30122, USA
+1-678-830-4877
info@aacehealthcare.org
HOME
Career
Refer a Patient or Caregiver
Contact
HOME
Career
Refer a Patient or Caregiver
Contact
Applications
Care With Passion
Job Application
Name
*
First
Last
*
Last
Social Security Number
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Present Address
*
Enter your full address including house number, city, and zip code
Permanent Address
*
Enter your permanent address including house number, city, state and zip code
Email
*
Phone
*
Are you a citizen of the United States?
*
Yes
No
If no, do you have a valid work permit?
*
Yes
No
If you are under 18, can you furnish a work permit?
*
Yes
No
Employement Desired
*
Full Time
Part Time
Temporary
Seasoner
Position You Are Applying For
*
CNA, CARE AIDE , SITTER , LPN or RN
Date You Can Start
*
Enter date you are most confortable to start working
Expected Salary
*
Enter expected hourly pay
Are You Employed Now?
*
Yes
No
If so, can we contact your present employer?
*
Yes
No
Have you ever applied to this company before?
*
Yes
No
Are you on layoff and subject to recall?
*
Yes
No
Will you travel if required?
*
Yes
No
Will you relocate if job requires it?
*
Yes
No
Will you work overtime if required?
*
Yes
No
Are you ready to meet the attendance requirement of this position
*
Yes
No
Have you ever been Bonded
*
Yes
No
Have you ever been convicted of Felony in the past 7 years?
*
Yes
No
Such conviction may be relevant if job related, but does not bar you from employment. If yes - explain
*
Driver's Licence
*
State
*
Enter state where your driver's license if approved
Are you currently studying?
*
Yes
No
High School
*
Enter name of your high school
Address of your high school
*
Attended From - To?
*
Did you graduate?
*
Yes
No
Degree received
*
College
*
College Address
Attended From - To?
*
Did you graduate?
*
Yes
No
Degree Received
*
Any other certificates received
*
List other certificates you have received with time period of study
Job Experience / Previous employer
*
Enter job experience with responsibilities, contact details of the company and salary received per hour
References
*
Enter at least 2 references, listing full name, address, phone, email, work information and position
Emergency contact
*
Enter your full emergency contact details
Reporting to work with impaired abilities; or the possession, consumption or distribution of drugs or alcohol on company premises and/or worksites, shall be grounds for disciplinary action, including discharge. A condition of employment includes willingness on the part of the applicant or employee to agree to physical examination, polygraph and/or substance testing, if required by the company. We are committed to operating a drug free workplace. Violations of our drug and alcohol policy will result in dismissal.
*
Agree
It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the employer's service if I have been employed. Furthermore, I understand that just as I am free to resign anytime, the Employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the Employer has the authority to make any assurances to the contrary.
*
Agree
I give the employer the right to investigate all police, driving, and personal records and references, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organization for furnishing such information.
*
Agree
The Employer is an Equal Opportunity Employer. The Employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, State or Federal law.
*
Agree
Any controversy of any kind arising between the parties under this agreement or otherwise (or any agent, officer, director or affiliate of any party), including but not limited to common law, statutory,tort or contract claims, will be submitted to mediation and failing settlement in mediation, to binding arbitration. Unless otherwise agreed a mediation and arbitration designated by staff professionals will govern any mediation and arbitration. The parties will select the mediator or arbitrator from the designated company panel of mediators and will notify the designated company, in writing, to initiate the selection process. The arbitration will be subject to and governed by the provisions of the Federal Arbitration Act. 9 U.S.C. Section 1-et seq. The parties hereto stipulate that this agreement involves matters affecting interstate commerce.
*
Agree
This application is current for 60 days. At the conclusion of this time if I have not heard from the Employer and still with to be considered for employment, it will be necessary to fill out a new application.
*
Agree
Applicant's name
*
Date
*
Confirm your application is complete and correct
*
Yes
No
Submit
Δ