Private Care Solutions — Registry Application

Please complete every section below as accurately as possible. Fields marked with * are required.

When you submit, this application goes straight to our office — you don't need to download, print, or email anything.

1.Applicant Information

Full Name*

Address*

City*

State*

Zip*

Date of Birth*

Gender

Male Female

Social Security Number*Required for background check

Phone Number*

Email Address*

Languages Spoken (optional)

2.Position Applying For*

Registered Nurse (RN) Licensed Practical Nurse (LPN) Certified Nursing Assistant (CNA) Home Health Aide (HHA) Companion Caregiver

3.Licensing & Certification

License / Certification Type (if applicable)

4.Transportation

Do you have a reliable form of transportation?*

Yes No

5.Work Eligibility

Are you legally eligible to work in the U.S.?*

Yes No

7.Education & Training

Highest Level of Education Completed (optional)

Health-Related Certifications or Degrees (include completion date)

8.Employment History

Current Employer

Employer Name

Contact Number

Position

Dates of Employment (from / to)

Past Employer 1

Employer Name

Contact Number

Position

Dates of Employment (from / to)

Past Employer 2

Employer Name

Contact Number

Position

Dates of Employment (from / to)

9.Medical History & Health Status

Do you have any allergies?

Yes No

If yes, please specify

Do you have any physical limitations or medical conditions?

Yes No

If yes, please specify

10.Professional References

Provide two professional references who can speak to your skills, work ethic, and reliability in a healthcare setting.

Reference 1

Company Name

Contact Person*

Contact Number

Email Address*

Reference 2

Company Name

Contact Person*

Contact Number

Email Address*

12.Criminal Background Check

Have you ever been convicted of a criminal offense?*

Yes No

If yes, please explain

I authorize Private Care Solutions to perform a background check, including criminal history and professional license verification as necessary.

Signature (type full name)*

Date*

13.Acknowledgments & Signature

I certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that providing false information could disqualify me from participating in the registry or result in removal at any time.

Signature (type full name)*

Date*

Printed Name*

Date*

Our office typically reviews new applications within 2 business days.

✓

Application Submitted

Thank you — your registry application has been received. Head back to the certification page to finish uploading your documents; it'll already show this step as complete.

Return to Certification Page