Employment Opportunities

Pre-Employment Screening Form

Our starting salary for Personal Care Assistants is $12.00 per hour for CNAs and PCTs.

All fields required, unless indicated.

Name (required)

In what county do you live?

Primary Phone No: (required)

Alternate Phone Number: (Optional)

Email Address (required)

Check the box to verify that you have, in your possession, the original of each document below. Must include expiration date for each.

Georgia CNA Certificate-Expires:

National PCT Certificate - Expires (Optional):

CPR Certification - Expires:

First Aid Certification-Expires:

Driver's License or State ID - Expires:

Date of most recent TB Skin Test or X-Ray - Read on:

Do you a valid Social Security Card?:

If you do not have ALL of these documents, please stop here. We are not able to schedule an interview if any of these is missing. After you have secured all current original items listed, return to this page and complete this form.

How much experience do you have as a certified caregiver?:

Please include the number of years and/or months

In what counties are you willing to work?:

Have you applied or worked with us before? If yes, when?


Please indicate what days and general time ranges you would be available to accept assignments.
You’ll be asked to provide more specific times during the hiring process.

Morning (between 6:00AM – 12:00PM):

Afternoon (between 12:00PM – 6:00PM):

Evening (between 6:00PM – 12:00AM):

How did you hear about us? Please include a name, if someone has referred you (Optional):

Please note any comments or clarifications you may wish to add (Optional):