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Pink Scrubs Home Care — Employment Application Form.

Thank you for your interest in joining Pink Scrubs Home Care. Please complete every field below. Incomplete applications may delay consideration. Pink Scrubs Home Care is an equal opportunity employer.

POSITION INFORMATION

Date
Month
Day
Year
Employment Type Desired
Full-Time
Part-Time
PRN / As-Needed
Overnight/Live-In
Are you at least 18 years of age?
Yes
No
Do you have reliable transportation?
Yes
No
Do you have a valid driver's license?
Yes
No

PERSONAL INFORMATION

Are you legally authorized to work in the United States?
Yes
No

CERTIFICATION & QUALIFICATIONS

Certifications held (check all that apply)
CNA
HHA
CPR/First Aid
PCA
Prior home care / caregiving experience?
Yes
No
Select all What you are Comfortable with.
Do you smoke or use tobacco products?
Yes
No

AVAILABILITY

EDUCATION

EMPLOYMENT HISTORY

Please list your two most recent employers, beginning with the most recent. Leave blank if not applicable.

Employer 1 (Most Recent)

Kindly submit details in full in th space provided

May we contact this employer?
Yes
No
Employer 2
May we contact this employer?
Yes
No

PROFESSIONAL REFERENCES

Please list three professional references (not related to you).

BACKGROUND INFORMATION

Have you ever been convicted of a felony? (A conviction will not necessarily disqualify an applicant from employment.)
Yes
No
Do you consent to a background check and drug screening as a condition of employment?
Yes
No
Have you ever had a caregiver, CNA, or nursing license/certification revoked or suspended?
Yes
No

APPLICATION CERTIFICATION

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any false statements or omissions may result in disqualification from consideration or, if discovered after hire, termination of employment. I authorize Pink Scrubs Home Care to verify the information provided, including contacting references and previous employers, and to conduct a background check and drug screening. I understand that this application does not constitute an offer of employment.

Date
Month
Day
Year
Pink Scrubs HomeCare

Pink Scrubs
Home Care

Providing dignified, non-medical in-home care services for the residents of Waxahachie and surrounding areas.

Contact Us

Email: info@pinkscrubshomecare.com

Phone: (469)553-8850

Main Office Address: 10819 Baucum RD,
Waxahachie, TX 75167

Available 24/7

Need immediate assistance? Our care coordinators are standing by around the clock.

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​Call now →

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