Apply for Caregiver Application

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:Caregiver Application
ID:GHEC_CG
Resume
* Resume:
Supported formats: Word, PDF, RTF, Text, and HTML.
  - or Upload from:
 
Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
* Social Security Number:
* Date of Birth:
* Gender:
Required for TB testing.
* Emergency Contact Name:
* Emergency Contact Phone:
* Emergency Contact Email:
Attachments
* Cover Letter:
You can type in a Cover Letter or Copy/Paste from an existing document.
Application for Employment
PERSONAL INFORMATION
Yes   No
Yes   No
Yes   No
EDUCATION

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School 1

Yes   No

School 2

Yes   No

School 3

Yes   No

School 4

Yes   No

School 5

Yes   No
EMPLOYMENT HISTORY

Give your full employment record, starting with your current or most recent employment

Employer 1

Yes   No

Employer 2

Yes   No

Employer 3

Yes   No

Employer 4

Yes   No

Employer 5

Yes   No
REFERENCES

Please provide three references (not relatives).

Reference 1

Reference 2

Reference 3
ADDITIONAL INFORMATION
Yes   No
Yes   No
VA   Keystone First   Amerihealth Caritas   UPMC   Private Pay   UNKNOWN
AUTHORIZATION

The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

Identification Information
If you do not upload this information it will delay the hiring process.

Acceptable forms of identification include:
• Passport or Passport Card
• Permanent Resident Card
• State issued Driver's License or ID
• School ID (with a photo and valid school year)
• Voters Registration Card
• Military ID

* UPLOAD A PHOTO OF YOUR IDENTIFICATION
* Identification Number
* Identification Issuing State
* Have you been a resident of Pennsylvania for more than 2 years?
Yes
No
If your ID was issued outside of Pennsylvania OR is less than 2 years old, you’ll need to provide proof of Pennsylvania residency. This can be a utility bill, identification, court order documents, benefits statements, etc. The document must include your name, PA address, and a date of more than 2 years ago.

If you have not been a resident of PA for more than 2 years, fingerprint background checks are required.

Providing this now will speed up the process.

UPLOAD PROOF OF RESIDENCY
TB Testing Requirements
You may submit existing TB Test Results OR we can submit a request for you to take a new test.
* Do you have TB Test Results already?
Yes
No

If yes, you may submit prior test results if they meet the following criteria:
• Must be within the last 11 months.
• Must be a 2-Step Skin Test OR Blood Test.
• If it shows a positive result, the accompanying Chest X-Ray must be included.
• Results must include the caregiver’s full name, date of test, and the test result (positive or negative).
• Screenshots are accepted if all required elements are clearly visible.

UPLOAD TB RESULTS

If the results do not meet our requirements, you will be asked to upload additional documentation OR take a new TB Test.

Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
Race/Ethnicity:
American Indian or Alaska Native
Black or African American
Hispanic or Latino
Asian
White (Not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander
Two or More Races
I Choose Not to Respond
Have you ever served in the military? (Please check all that apply)
Yes
No
I Choose Not to Respond

I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.
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