Provider ApplicationFill out the online form or download the AAH Provider Application and bring by our office. Today's Date MM DD YYYY Name First Name Last Name Phone (###) ### #### Email Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country OTHER RELEVANT INFORMATION Are you currently providing Home Help? Yes No If yes, please describe Did anyone refer you to apply to Assisting At Home? TRAINING AND CERTIFICATION Please check if you have had recent training in this area and can provide proof of training, such as certificates. First Aid Yes No CNA (certified nursing assistant) Yes No CMH (Community Mental Health) Yes No CPR (cardiopulmonary resuscitation) Yes No Other Home Help/Home Care relevant training, skills or experience? Please list: Are there any skills for which you would like to see training offered? Please list: The Company will only work with US citizens and aliens lawfully authorized to work in the US. Are you a US citizen? Yes No If No, are you lawfully authorized to work in the US? Proof of citizenship or immigration status will be required upon employment. Yes No WORK HISTORY Please list any HOME HELP/HOME CARE job(s) that you have had lasting 30 days or more in the last five years that we may call as references. Begin with your most recent work. If you do not have HOME HELP/HOME CARE work references, list any other work. We must reach three references, preferably for current or previous employment, or from a school you have recently attended. Employer or Consumer Phone (###) ### #### Permission to call Yes No Employer or Consumer Phone (###) ### #### Permission to call Yes No EDUCATION HISTORY High School Diploma Yes No College Diploma Yes No Any other courses or training you have taken Please check boxes indicating if you are experienced in, or willing to assist in any of the following areas. We cannot guarantee consumers calling you will match all your preferences. We encourage you to consider performing all tasks and serving all consumers: Work with persons who are: Mobility Assistance Yes Maybe No Experienced Bathing Yes Maybe No Experienced Dressing Yes Maybe No Experienced Grooming Yes Maybe No Experienced Feeding Yes Maybe No Experienced Toileting, diapers, bed, pans, etc. Yes Maybe No Experienced SCHEDULE PREFERENCES Are you willing to work: Routine Care Holidays Backup Care Emergency on-call Mornings * Yes No Afternoons * Yes No Evenings * Yes No Are you willing to work for more than one consumer? Yes No Are you willing to do light housekeeping, laundry, cooking/meal prep, linen changes, grocery shopping? Yes No List any other name used in the last 7 years (Maiden Name) Gender Male Female Other Date of Birth MM DD YYYY CRIMINAL BACKGROUND CHECK Have you been convicted of a felony? Yes No Have you been convicted of a misdemeanor? Yes No Please Read Carefully I certify that I am at least 18 years of age and the facts contained in this application are true and complete. I understand that falsified statements on this application shall be considered cause for discharge. I understand that any offer of contract made by Assisting At Home, LLC is contingent upon the satisfactory results of a motor vehicle report and a criminal background check. I understand that any opportunity to be accepted as a member of the Assisting At Home, LLC is contingent upon the satisfactory results of a motor vehicle report and a criminal background check. In addition, I am willing to have a drug test at any time and at an approved location whenever it is asked of me by the administration of Assisting At Home, LLC. Failure to comply to any request to take a drug test is grounds for dismissal. Any finding of a positive on any drug test is also grounds for immediate dismissal. I further acknowledge and agree that my contract with Assisting At Home, LLC may be terminated, with or without prior notice, at any time, at the will of Assisting At Home, LLC or me, with or without cause. No representative or employee of the Company has the authority to enter into any contract or agreement with a client within two (2) years of termination from the Company without expressed permission of Assisting At Home, LLC. I also understand that if I enter into such a contract or agreement with an Assisting at Home, LLC client, be it past or present, I will be liable to the Company for damages up to $3,000. I will report any changes in my criminal history status that occur after this date. I give Assisting At Home, LLC or its designee permission to share my criminal history and other relevant information in my file with the individual consumers who are looking for providers. I understand that: I am filling out this application to possibly list my name on the registry but the application is no guarantee of employment; a consumer must agree to select me for employment; and Assisting At Home, LLC is not responsible in any way for finding employment for me with a consumer. This application will be maintained in the Company's active files for three months only, unless renewed. I acknowledge that I have read and understand these terms. I accept these terms. I am not a robot. * Check this box Click here to email a copy of your north carolina drivers licenses.Thank you for filling out this application. You will be contacted by someone from our team!
