Employment Application

Thank you for your interest in being a valuable asset of QLHC. Fill out the application below & if we are hiring & you qualify, someone will contact you.

If we aren't currently hiring, we will keep your application on file for future reference.

Personal Information

First & Last Name*

Date of Birth*

Are you a U.S. citizen?* Yes No

Are you eligible to accept permanent employment in the U.S.? Yes No

Have you ever been convicted of a felony?* Yes No

Give the date, location & discription of your case. (2000 chars left)

Position Desired

CNA I
CNA II
LPN
RN
Homemaker
Office Manager
Field Supervisor
Administration
Other

Describe Other

Full-Time Part-time PRN

Days Available Mon.
Tue.
Wed
Thu.
Sat
Sun

Hours available

How did you hear about this position?

Do you have reliable transportation? Yes No

Desired Salary

Date Available

Contact Information

Street Address*

City*

State*

Zipcode*

Phone*

Emergency Contact

Emergency Contact Person

Emergency Contact Relationship

Emergency Contact Phone

Emergency Contact Street Address

City

State

Zipcode

Education

High School

Name & Location

Last Year Attended

Did You Graduate? Yes No

College

Name & Location

Date Attended

What Was Your Major?

Did You Graduate? Yes No

What Degree Did You Earn?

How Many Credit Hours Did You Complete?

Graduate School

Name & Location

Date Attended

Did You Graduate? Yes No

What Degree Did You Earn?

How Many Credits Did You Complete?

Other Training & Vocational Schools

Name & Location

Type Of Training (include date & certification received)

License & Certifications

List Fields Of Work for Which You Are Licensed, Registered, Or Certified. Include Numbers, Dates, & Source Of Issuance

Has your license ever been revoked or suspended or are you involved in any proceeding that could affect your license or cetifications Yes No

Please Explain

Employment History

Are you currently employed? Yes No

May we contact your current employer? Yes No

Most Recent

Date of employment (from - to)

Name of Company

Phone Number

Address

Starting & Ending Salary

Job Title & Description (1000 chars left)

Supervisor

Next Most Recent

Date of employment (from - to)

Name of Company

Phone Number

Address

Starting & Ending Salary

Job Title & Description (1000 chars left)

Supervisor

Next Most Recent

Date of employment (from - to)

Name of Company

Phone Number

Address

Starting & Ending Salary

Job Title & Description (1000 chars left)

Supervisor

Thank you for your application submission!

Quality Life Home Care

148 East St. (Lower Level), Pittsboro, NC 27312 ~ 919.545.2027, 919.545.2028

Employment Application