New Application FormPlease enable JavaScript in your browser to complete this form.Persona Information - Step 1 of 7Positions(s) Applying ForRNCNACOMPANION/SITTERPersonal InformationIf you have lived at current address less than one year, list previous addressDOB *SSN *NameFirstLastCurrent AddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePrevious AddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome PhoneCell PhoneEmergency Contact's NameRelationshipPhoneNextSPECIAL LICENSES, CERTIFICATION OR REGISTRATION1. License/Certification TypeLicense/Certification No.StateExpiration Date2. License/Certification TypeLicense/Certification No.StateExpiration DateCPR Expiration DateLast Physical Exam DateLab TB/Chest X-Ray DateUpload Your Certificates Click or drag files to this area to upload. You can upload up to 5 files. PreviousNextGENERAL INFORMATIONValid Driver’s LicenseState IssuedExp. DateUpload Driver's LicenseMake & Model of VehicleYear of vehicleAuto In CoPolicyExp. DateHave you ever submitted an application here before?YESNOIf yes, when?Have you ever been employed here before?If yes, when?Are you able to perform the tasks according to the job description without accommodation?YESNOHave you ever been convicted of a felony or misdemeanor crime? (This does not apply if the conviction has been expunged, is contained in a sealed record, or was a juvenile conviction.) A criminal conviction will not necessarily bar you from employment. We will consider the nature of the crime, the time that has expired since its occurrence and any rehabilitation you have undergone. If yes, state the basis for each conviction and the date of the convictionYESNOHow did you hear about MIR HOME CARE, INC?PreviousNextAVAILABILITYPlease indicate the days of the week as well as the earliest and latest times that you are available for work.What date are you available to begin work?Please check all areas of availabilityMorningsAfternoonEveningsOvernightsWeekdaysWeekendsShiftsType the shifts you're availablePREFERENCESFULTONCOBBDOUGLASDEKALBGWINNETTFORSYTHCLAYTONPlease check all the counties in which you are willing to workPreviousNextEDUCATIONSchool NameSchool Type: High SchoolCity, StateMajor/SubjectGraduateYesNoSchool NameSchool Type: Vocational/TechnicalCity, StateMajor/SubjectGraduateYesNoSchool NameSchool Type: College/UniversityCity, StateMajor/SubjectGraduateYesNoPreviousNextMOST RECENT EMPLOYERCompany NameCityStatePhoneAre you currently working for this employer?YesNoCan we contact them if needed?YesNoFromJob start dateToJob end dateToJob end dateJob TitleSupervisor's NameSalaryIn dollarsPerHourHourWeekMonthReason for leavingSECOND MOST RECENT EMPLOYERCompany NameCityStatePhoneAre you currently working for this employer?YesNoCan we contact them if needed?YesNoFromJob start dateToJob end dateToJob end dateJob TitleSupervisor's NameSalaryIn dollarsPerHourHourWeekMonthReason for leavingPreviousNextREFERENCESPlease notify the references in advance as we will contact them.Full NameName of Reference 1PhonePhone Number of Reference 1Best time to callBest time to call reference 1RelationshipRelationship with reference 1Full NameName of Reference 2PhonePhone Number of Reference 2Best time to callBest time to call reference 2RelationshipRelationship with reference 2CERTIFICATION AND RELEASEI certify that I have read and understand this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship MIR HOME CARE, INC, and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.PreviousMessageSubmit The Application