HELP HOMECARE SERVICES LLC

Join Our Care Team

One application — everything in one step. Documents come later at onboarding.

📍 2180 ELM STREET

About You

Full Name *

Date of Birth *

Street Address *

City *

State *

ZIP *

Email *

Phone *

Emergency Contact

Name *

Relationship *

Phone *

Position

Primary Position *

Shift Preference *

Are you OK working around pets? *

Availability *

Do you have prior caregiving experience? *

Certifications / Licenses *

Work Eligibility

Are you 18 years of age or older? *

Are you legally authorized to work in the U.S.? *

Will you require sponsorship for a work visa? *

Basic Skills Checklist — Homecare Aide

Check every task you're comfortable performing. This helps us match you with the right clients.

Employment History

Most recent first. Skip any field that doesn't apply.

Job 1

May we contact this employer?

Professional References

Supervisors, colleagues, or instructors who can speak to your work.

Reference 1

Reference 2

Background Disclosure

A criminal record alone is not an automatic bar to employment. We evaluate case-by-case per EEOC guidance.

Have you ever been convicted of a crime (other than minor traffic violations)? *

Driver License (optional)

📎 Snap a photo of the front of your license. JPG, PNG, HEIC, PDF, Word. Max 10MB. All other documents (resume, SSN card, TB test, CPR) are collected during onboarding after you're hired.

🪪 Driver License

Photo of front — optional, you can upload later

Tell Us Your Story (Optional)

Why do you want to work in care?

Certify & Sign

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any false statement may disqualify me from employment or be cause for termination. I authorize the verification of all information provided.

I agree and certify the above is true. *

Full legal name (typed signature) *

By submitting this application, you agree to be contacted about employment opportunities by phone and email. Your information is confidential and stored securely.

Optional — SMS / Text Message Updates: If you would also like to receive text-message updates about your application, interview scheduling, and onboarding from PrimeCare Systems and your employing agency, you may opt in below. SMS is completely optional — submitting this application does not require SMS consent, and your application will be reviewed the same either way. We will reach you by phone call and email regardless. Message frequency varies. Message and data rates may apply. Reply STOP at any time to unsubscribe, or HELP for assistance.

Optional: Yes, I would also like to receive SMS / text-message updates at the mobile number provided. (Not required — leave unchecked to skip.)