Caregiver Application | Acaste Care Solutions

1. Position & Location

Position Applying For * State You Are Applying to Work In * Preferred City / County * Employment Type * Desired Start Date How Did You Hear About Us?

2. Applicant Information

Please do not provide a Social Security number on this application.

Full Legal Name * Preferred Name Mailing Address * Phone Number * Email Address *

Are You 18 or Older? *

Yes No

Reliable Transportation? *

Yes No

Driver's License Number (if driving clients) Driver's License State

Smartphone / Internet Access for Scheduling? *

Yes No

3. Work Eligibility

Legally Authorized to Work in the U.S.? *

Yes No

Will You Require Employment Sponsorship Now or in the Future? *

Yes No

Fair Chance Notice: Do not provide criminal-history information on this application. Any legally permitted background-check process will occur separately at the appropriate stage of hiring.

4. Certifications & Caregiving Experience

Prior Caregiving / Home Care Experience? *

Yes No

Years of Experience Certification / License Number(s) Expiration Date(s)

California Home Care Aide (HCA) Registry Number

I will register within the required timeframe, if applicable.

Hawaii CNA Certification Number (if applicable)

Texas Nurse Aide Registry Number (if CNA)

5. Skills & Experience

Care Skills

Most Recent Employer

Employer NamePosition Dates EmployedReason for Leaving

May We Contact This Employer?

Yes No

Languages Spoken Besides English Maximum Weight You Can Safely Lift / Assist (lbs)

Comfortable Working in Homes With Pets?

Yes No

6. Availability

Travel Radius From Home (miles)

Available for Short-Notice / Emergency Shifts?

Yes No

7. Professional References

Please provide 2–3 professional references. Non-family references are preferred.

Reference 1 *

Name *Relationship *Phone *Email

Reference 2 *

Name *Relationship *Phone *Email

Reference 3

NameRelationshipPhoneEmail

8. Acknowledgments & Signature

I understand that Acaste Care Solutions is committed to equal employment opportunity and considers applicants without unlawful discrimination. I understand that, where permitted by applicable law, employment with Acaste Care Solutions is at will and that this application is not a contract or guarantee of employment. I certify that the information I have provided in this application is true and complete to the best of my knowledge. I understand that material misrepresentations or omissions may affect consideration for employment or, if discovered after hire, may result in appropriate employment action subject to applicable law.

Typed Signature *Date *

Separate post-application documents: If applicable, Acaste will provide separate forms for background-check disclosure/authorization, motor-vehicle-record authorization, and required health/TB screening. Do not submit Social Security numbers, medical records, or criminal-history information through this application.

Caregiver Employment Application

1. Position & Location

2. Applicant Information

3. Work Eligibility

4. Certifications & Caregiving Experience

5. Skills & Experience

6. Availability

7. Professional References

8. Acknowledgments & Signature