Pure Heart Home Care Jobs - Online Application, Elderly Health Care Jobs, Home Care Jobs, Senior Care Jobs

Pure Heart Care - Online Application

Pure Heart Care (PHC) has developed an online application that immediately allows us to access your information as soon as you apply for a position. We can easily match your experience and skills with an available client’s needs and preferences. Once you have completed the online application and submitted it to PHC, you will receive a confirmation email. Then, as soon as a position for which you are qualified becomes available, we will contact you directly. Please make sure the contact information as well as certifications are accurate before you submit your application. Please upload a photo of yourself. Thank you!

Once you join our team of compassionate caregivers, you can easily make changes to your profile online as well. Simply log in to your account and make changes (including disabling and your profile when you are no longer searching for employment); the system is updated frequently. For example, if your address changes, just log in and post your new address. It’s that simple!

Preferred Employment

"*" indicates required fields.

Select your employment preference:

Contractor

Employee

Personal Information

First Name:	*	Last Name:	*
Social Security Number:	*	Email Address:	*
Address:	*	:
City:	*	State:
Zip Code:	*	Country:
Home Phone:	*	Cell Phone:	*
Date of Birth:	(mm/dd/yyyy)	Marital Status:
Gender:		Nationality:
Height:	*	Weight:	lbs.
Emergency Contact Name:	*	Emergency Contact Number:	*
Is English your first language:		Other languages you speak fluently:
Willing to relocate:		If so, where?
Do you drive?		How far are you willing to drive?
Drive License Number:		Registered State:

Work Preference

Companion Care Experience:		Personal Care Experience:
Housekeeping Experience:		Cook/Prepare Meals Experience:
Will work with children:		Help with pet care:
Date Available:	(mm/dd/yyyy)	Position Apply For:
CNA/HHA or Certificate Number:		State:
Weekly Live-In Services:		Hourly Live-Out Salary:
Employment Requested:		Available for Emergency/Short Term:

Past Experience(s) (Very Important - check only those you have 3 months or more hands on experience)

Are you Certified Med. Adm. or Med. Tech:		Blood Pressure Check:
Glucose Blood Sugar Check:		Colostomy Bag:
Insulin Shots:		Feeding Tube:
First Aid Certified:		CPR Certified:
Alzheimer`s/Dementia:		Cancer:
Diabetes :		Hospice:
Do you have Pediatrics Experience Explain:
Other Experiences/Interest/Hobbies:

Education

High School Name:
College Name/Location:		Degree Earned:
Attended From:	(mm/dd/yyyy)	Attended To:	(mm/dd/yyyy)
Major/Minor:		Diploma Received:
Vocational/Nursing School:
Location/Address:		Attended From:
Attended To:		Certificate/Diploma:

Employment History

Name Of Employer 1:		Name Of Employer 2:
Address Line 1:		Address Line 1:
Address Line 2:		Address Line 2:
City:		City:
State:		State:
Zip Code:		Zip Code:
Employed From:	(mm/dd/yyyy)	Employed From:	(mm/dd/yyyy)
Employed To:	(mm/dd/yyyy)	Employed To:	(mm/dd/yyyy)
Employer Phone:		Employer Phone:
Job Title:		Job Title:
Supervisor Name:		Supervisor Name:
Reason For Leaving:		Reason For Leaving:

Professional References

Reference Name 1:		Reference Name 2:
Address:		Address:
Occupation:		Occupation:
Phone:		Phone:

Personal References

Reference Name 1:		Reference Name 2:
Address:		Address:
Occupation:		Occupation:
Phone:		Phone:

Background

Have you ever been convicted of a felony or a first degree misdemeanor?

Have you ever pled no contest or guilty to a felony or a first degree misdemeanor?

Are you a U.S citizen or are you legally authorized to work in the U.S.?

The above information is true and correct. If employed, I will be required to provide original documents which verify my identity and right to work in the United States under the Immigration Reform and Control Act (IRCA) of 1986. I hereby do authorize Pure Heart to obtain all confidential employment, background check & references needed for employment.

Alien Registration Number:

Passport Number:

Acknowledgement & Signature:

Date Signed:

Upload Photo: