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610-624-9222
Home
About
Services
Employment
Caring for your family like it's ours.
FAQs
Testimonials
Contact Us
610-624-9222
Apply Online
Please complete the form below.
If preferred, download and print the application
here
.
Fax: 610-664-3373
Personal information
Name
*
First Name
Last Name
Address
*
Address, City, State, Zip
Phone
*
(###)
###
####
Email
*
Are you at least 18 years of age?
*
Yes
No
Do you have a legal right to work in this country?
*
Yes
No
Will you now or in the future require sponsorship for employment visa status (e.g., H1B visa status)?
*
Yes
No
Have you ever been convicted of a felony?
*
Yes
No
Have you ever been convicted of Medicare or Medicaid fraud?
*
Yes
No
If Selected For Employment Are You Willing To Submit to a Pre-Employment Drug Screening Test?
*
Yes
No
Position
What position are you applying for?
*
HHA (Home Health Aide)
CNA (Certified Nurse's Assistant
Either
Are you certified?
*
Yes
No
Available Start Date
*
MM
DD
YYYY
What is your desired pay (per hour)?
*
$
Employment Desired
*
Full Time
Part Time
Seasonal / Temporary
Shift Availability
Are you willing to travel:
*
30 minutes or less
30 minutes to an hour
Monday
*
Please check on the appropriate box or boxes for your availability
Day Shift (8 am - 4 pm)
Evening Shift (4 pm - Midnight)
Overnight Shift (Midnight - 8 am)
Not Available
Tuesday
*
Please check on the appropriate box or boxes for your availability
Day Shift (8 am - 4 pm)
Evening Shift (4 pm - Midnight)
Overnight Shift (Midnight - 8 am)
Not Available
Wednesday
*
Please check on the appropriate box or boxes for your availability
Day Shift (8 am - 4 pm)
Evening Shift (4 pm - Midnight)
Overnight Shift (Midnight - 8 am)
Not Available
Thursday
*
Please check on the appropriate box or boxes for your availability
Day Shift (8 am - 4 pm)
Evening Shift (4 pm - Midnight)
Overnight Shift (Midnight - 8 am)
Not Available
Friday
*
Please check on the appropriate box or boxes for your availability
Day Shift (8 am - 4 pm)
Evening Shift (4 pm - Midnight)
Overnight Shift (Midnight - 8 am)
Not Available
Saturday
*
Please check on the appropriate box or boxes for your availability
Day Shift (8 am - 4 pm)
Evening Shift (4 pm - Midnight)
Overnight Shift (Midnight - 8 am)
Not Available
Sunday
*
Please check on the appropriate box or boxes for your availability
Day Shift (8 am - 4 pm)
Evening Shift (4 pm - Midnight)
Overnight Shift (Midnight - 8 am)
Not Available
Automobile
Do you drive?
*
Yes
No
Do you have a valid driver's license?
*
Yes
No
In which state is your license issued?
Do you own a car?
*
Yes
No
Vehicle Make
Vehicle Model
Vehicle Year
Do you currently have auto insurance?
*
Yes
No
Education
Please list your education
*
Name of school, location, years attended, degree received, major.
References
Please list your references
*
Name, title, company, and phone number
Employment History
Please list your employment history
*
Company name, company location, your job title, dates employed, starting pay rate and ending pay rate.
Pets
Are you willing to provide service to a client with a pet?
*
Yes
No
If yes, which ones?
Dog
Cat
Both
Smoking
Are you a smoker?
*
Yes
No
Are you willing to provide service to a client that smokes?
*
Yes
No
EEO Information
WillaCare, LLC is subject to certain governmental record keeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites employees and applicants to voluntarily self-identify their gender, race and ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual. Completion of this data is voluntary and will not affect your opportunity for employment or terms or conditions of employment. If you choose not to identify, please select "Prefer not to identify." Explanation of the Categories: Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. White (Not Hispanic or Latino): A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Black or African American (Not Hispanic or Latino): A person having origins in any of the Black racial groups of Africa. Asian (Not Hispanic or Latino): A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. American Indian or Alaskan Native (Not Hispanic or Latino): A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Two or More Races (Not Hispanic or Latino): All persons who identify with more than one of the above five races.
Gender:
*
Female
Male
Prefer not to identify
Race / Ethnicity:
*
Hispanic or Latino
White
Black/African American
Asian
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander
Two or more races
Prefer not to identify
Disability Information
Voluntary Self-Identification of Disability Form CC-305 OMB Control Number 1250-0005 Expires 1/31/2020
Why are you being asked to complete this form? Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way. If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier. How do I know if I have a disability? You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to: • Blindness • Deafness • Cancer • Diabetes • Epilepsy • Autism • Cerebral palsy • HIV/AIDS • Schizophrenia • Muscular dystrophy • Bipolar disorder • Major depression • Multiple sclerosis (MS) • Missing limbs or partially missing limbs • Post-traumatic stress disorder (PTSD) • Obsessive compulsive disorder • Impairments requiring the use of a wheelchair • Intellectual disability (previously called mental retardation) Reasonable Accommodation Notice Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment. __________________________________________________ iSection 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.
Please select one of the options below:
*
Yes, I have a disability (or previously had a disability)
No, I don't have a disability
I don't wish to answer
Veteran Groups Survey
Federal contractors are required to implement affirmative action procedures in employing veterans from the targeted groups identified below. Federal contractors also are required to report annually on the inclusion of veterans from the groups in their current workforce and in their new hires. Current employees are requested to provide the information below so that the employing organization can comply with these important federal mandates (if applicable). Provision of the information requested below is voluntary and will be kept confidential by WillaCare, LLC. Disclosure or refusal to provide the information will not subject the applicant or employee to any adverse treatment and the information will be used only to support veteran’s programs in accordance with the appropriate regulations. Completion of this data is voluntary and will not affect your opportunity for employment or terms or conditions of employment. Please select the appropriate category below. If you choose not to identify, please select “Prefer Not to Identify.” Explanation of the Categories: Armed Forces Service Medal Veteran Any veteran who, while serving on active duty in the U.S. military, ground, naval, or air service, participated in the United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985 (61 FR 1209). Active Duty Wartime or Campaign Badge Veteran Any veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. Recently Separated Veteran (Please check and complete separation date if category applies to you.) Any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service. Please specify your date of discharge. Disabled Veteran One of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability.
Veteran Category:
*
Prefer Not to Identify
Armed Forces Service Medal Veteran
Active Duty Wartime or Campaign Badge Veteran
Recently Separated Veteran
Disabled Veteran
Non-Veteran
Signature Disclaimer
I certify that the answers given by me to the foregoing questions are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize WillaCare, LLC and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release WillaCare, LLC from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary., the employment relationship between WillaCare, LLC, and myself is terminable at-will, so both the company and I remain free to choose to end our work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledge that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.
I have read and agree to the disclaimer above.
*
I agree
I disagree
Thank you!
