ncschomecareservices@gmail.com
454 N Anderson Rd Suite 124, Rock Hill, SC 29730, United States
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Services
Child Care Services
Grooming
Feeding and Special Diet
Grocery Shopping
Mobility Assistance
Companionship
Medication Reminders
Laundry
Bathing and Hygiene
Nursing Services
Service Areas
Chester SC
Lancaster SC
Columbia SC
About Us
Employment
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Employment
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Employment
Personal Information
First Name
Address 1
M.I
Address 2
Last Name
City
Home Phone
State/Prov
Cell Phone
Postal Code
Work Phone
Position Applying For
Personal Care Aide
CNA
LPN
RN
Office Administrator
Email
SSN
How did you hear about us?
Other
Website
Indeed
Confirm SSN
Have you ever been convicted of a crime?
No
Yes
How long at this address ?
Date of Birth
Transportation
Do you have a car?
No
Yes
Driver’s License #
If you don’t have a car how would you get to work?
Expiration
Availability
How many hours can you work weekly?
Are you available to work nights?
No
Yes
Sometimes
Are you legally authorized to work in this country?
yes
No
Would you consider live-in?
yes
No
Employment Desired
Full Time
Part Time
Full or Part Time
Are you available to work weekends?
Yes
No
Available to Start Date
Are there any times you are not available to work?
Education
High School
Name
City
State/Prov
Level Completed
Degree
Major
College
Name
City
State/Prov
Degree
Major
Bus.or Trade School
Name
City
State/Prov
Degree
Major
Professional School
Name
City
State/Prov
Degree
Major
Attributes
Companionship
No
Yes
Dressing/Grooming
Yes
No
Meal Preparation
Yes
No
Transferring
Yes
No
Light Housekeeping
Yes
No
Incontinence Care
Yes
No
Bathing/Showering
Yes
No
Dementia / Alzheimers
Yes
No
Dementia / Alzheimers
Yes
No
Attributes
Company
From
To
Job Title
Reason Left
Duties
Supervisor
Phone
May we contact?
Yes
No
Company
From
To
Job Title
Reason left
Supervisor
Phone
May we contact
Yes
No
Professional References
Reference 1
Name
Relationship
Years Known
Phone
Reference 1
Name
Relationship
Years Known
Phone
Date
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