Application for EmploymentYOU ARE ON APPLICATION SECTION: ONE OF SIXStart your Career with Aegis Right Here.Aegis Home Care, LLC is an Equal Opportunity Employer and does not discriminate in hiring and/or employment on the basis of race, color, religious creed, national origin, sex, ancestry, or on the basis of age, or physical handicap unrelated to the ability to perform the work required. The questions on this application are intended to secure information to determine the applicant's qualifications for employment. This application will be given every consideration, however its receipt does not imply the applicant will be employed. Any omissions, misrepresentations, or falsifications of information on this application will result in rejection of the application and/or termination of employment.Section One: Basic InformationSection One: Basic InformationName* First Name Middle Last Name Date of ApplicationSocial Security Number*Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Telephone #*Alternative Phone/ ContactEmail* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Driver's License NumberExpiration Date MM DD YYYYHave you ever worked for Aegis Home Care before?*YesNoIf yes, where and when?What is the position you are applying for?*Nurse Assistant I/IIAttendant / CaregiverNurse SupervisorOtherPlease specify the job title:*New Hires will be subject to a urine drug test and skills test. Aegis Home Care, LLC complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Are you okay being tested for both?*YesNoAre you employed now?*YesNoMay we contact your present employer?*YesNoIf hired, can you present evidence of your legal right to work in this country?*YesNoIf hired, can you present verification that you meet legal age requirements to work?*(Note: a photograph may be required at time of employment)YesNoHave you ever been convicted of a criminal offense other than a minor traffic violation?*YesNoIf yes, state the nature of the offense(s), when and where convicted and the disposition of the case(s).Note: No applicant will be denied employment solely on the grounds of a conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position applied for may, however, be considered.Do you have a working smart phone?*YesNoSECTION TWO: EMPLOYMENT EXPERIENCE AND EDUCATIONYOU ARE ON APPLICATION SECTION: TWO OF SIXSection Two: Employment Experience and EducationAre you licensed or certified in any capacity of health or home care*YesNoName of license/certificationLicense/certification numberDate of expiration MM DD YYYYIssuing state AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Has your license/certification ever been revoked or suspended?YesNoIf yes, state reason(s), date of revocation or suspension and date of reinstatement.*EmploymentEmploymentList below present and past employment, starting with your most recent employment, for the last ten years. You must complete this section, even if attaching a resume. Name of Employer Phone Address Job Title Name of Supervisor Employed From To Pay Rate/ Salary Starting Pay Rate/ Salary Final Work Performed Reason for LeavingActions EditDelete There are no Employers. Add Employer Maximum number of employers reached. Please Confirm:* Check to confirm you have entered information above that covers your last 10 years of employmentOptional: Attach your resume here( accepted formats: pdf, doc, docx )Accepted file types: pdf, doc, docx.EDUCATIONName of High SchoolGrade CompletedSelect9101112Name of CollegeGrade CompletedSelect1234Name of Graduate / ProfessionalGrade CompletedSelect1234Please list and special training, honors, etcSECTION THREE: REFERENCESYOU ARE ON APPLICATION SECTION: THREE OF SIXSection Three: ReferencesPlease list people who will vouch for your work performance and attitude.*Please include at least one Supervisor. We require at least two references.NameCompanyPhoneNature of relationshipReferences Continued:*NameCompanyPhoneNature of relationship To add more than two references, click the button on the right to add extra rows.SECTION FOUR: UNDERSTANDING YOUR ROLEYOU ARE ON APPLICATION SECTION: FOUR OF SIXSection Four: Understanding Your RoleAegis Home Care, LLC maintains a variety of clientele, each having particular care routines and needs. As an Aegis Home Care, LLC Personal Attendant, some of the duties you will be required to perform involves lifting, bending, stooping and other repetitive movements and/or motions. Aegis Home Care, LLC Staff Personnel assess the needs of its clients prior to the staffing process to determine the level of care and qualifications required by an Attendant Employee providing care services. This assessment serves as the initial job description for the Attendant Employee providing care services for that particular client. Due to the nature of Aegis Home Care, LLC cases, the level of care and duties an Attendant Employee performs for a particular case may change on a daily basis. Any changes of duty requirements will be logged into the Activity Log at the residence of duty. All changes or modifications in the care of a client combined with the initial assessment of the client’s needs comprise the job description for the Attendant Employee for that particular case. The Questionnaire assists Aegis Home Care, LLC Staff Personnel to evaluate and determine the skill level and qualifications of its applicants for offering care assignments. Please answer the following questions:Are you available to work on weekends?*YesNoIs your driver’s license current and valid?*YesNoIf your driver's license is not current or valid, please explain below:*Do you feel competent to safely drive an Aegis Home Care, LLC client in an automobile?*YesNoIn the client’s automobile?*YesNoIn your automobile?*YesNoIf Yes in your automobile, is this vehicle fully insured?*YesNoIs it legally registered to operate?*YesNoHave you had a TB test taken in the past year?*YesNoDo you have any weight lifting restrictions, due to a back injury or other condition?*YesNoPlease describe your weight lifting restrictions*Do you smoke?*YesNoWill you provide care in a home where the client or family smoke?*YesNoIf Yes, which ones:*Will you provide care in a home where the client has pet(s)?*YesNoCat?*YesNoDog?*YesNoIndicate the areas you are willing to travel to for work:* Select All Chapel Hill Durham Pittsboro Sanford Apex Hillsborough Raleigh Cary Mebane Southern Pines Pinehurst Aberdeen Vass Eagle Springs CarthageHave you received training on correct and safe transfer procedures?*YesNoHave you done squat-pivot transfers?*YesNoDo you know how to care for patients with incontinence?*YesNoHave you received training on how to care for people with Alzheimer’s?*YesNoHave you received training on how to correctly care for people who are combative?*YesNoWill you provide care for people who are combative?*YesNoHave you received training on how to correctly care for a person with Parkinson’s disease?*YesNoWill you provide care for people with Parkinson’s disease?*YesNoDo you know how to safely and correctly bathe and wash a client?*Yes - Both male and female clientsYes - Male clients onlyYes - Female clients onlyNoWill you bathe and wash clients?*Yes - Both male and female clientsYes - Male clients onlyYes - Female clients onlyNoDo you know how to assist with complete personal hygiene care for clients?*Yes - Both male and female clientsYes - Male clients onlyYes - Female clients onlyNoDo you feel competent to safely and correctly assist with complete personal hygiene care for clients?Yes - Both male and female clientsYes - Male clients onlyYes - Female clients onlyNoDo you know how to correctly perform light housekeeping chores?*YesNoDo you know how to perform proper meal preparation in the home?*YesNoDo you know competent to safely and properly prepare meals in the home of a client?*YesNoHave you received training on how to care for HIV positive people?*YesNoWill you provide this type of care?*YesNoDo you know how to properly care for the terminally ill?*YesNoDo you feel you are competent to compassionately and properly care for the terminally ill?*YesNoDo you feel you could properly and professionally handle a situation where the client might pass away while you are there?*YesNoDo you know how to operate a Hoyer Lift?*YesNoWhich type(s) of lift?*ElectricManualBoth typesDo you know how to properly use Universal Precautions?*YesNoDo you know how to correctly make an occupied bed?*YesNoDo you know how to correctly take vital signs?*YesNoDo you know how to perform the Heimlich maneuver?*YesNoDo you know how to assist a client with glucose testing?*YesNoLast StepOnce you submit this form you will be taken to an e-signature page. Please read the terms carefully and sign to complete your application.CommentsThis field is for validation purposes and should be left unchanged.
