Private Care Solutions â€” Caregiver Application

Please complete every section below as accurately as possible, then attach the required documents near the bottom. Fields marked with * are required.

When you submit, everything goes straight to our office - you do not 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*

14.Required Documents

Resume

Resume (optional)PDF, DOC, or DOCX

✓Choose File

Identity & Eligibility

Driver's License*

✓Choose File

Social Security Card*

✓Choose File

Proof of Citizenship*Passport, birth certificate, or citizenship papers

✓Choose File

Direct Deposit Information*

✓Choose File

Health & Screening

Physical Exam*Dated within the last 6 months

✓Choose File

Background Screening (AHCA)*

✓Choose File

Licenses & Coverage

Professional License*

✓Choose File

CPR Card*

✓Choose File

Auto Insurance*

✓Choose File

Liability Malpractice Insurance*

✓Choose File

Continuing Education Certificates

OSHA / HIV / AIDS*

✓Choose File

Prevention of Medical Errors*

✓Choose File

Alzheimer's Disease & Dementia*

✓Choose File

Domestic Violence*

✓Choose File

Questions for the Office (optional)

Prefer to ask us directly? Email info@privatecaresolutionsfl.com or call 561-566-1700.

Our office typically reviews new applications within 2 business days.

✓

Application Submitted

Thank you - your application and documents have been received. Our office will review them and follow up if anything additional is needed.