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Call Us: 703-910-7081

Private Duty / Medicare / Medicaid
Serving Northern Virginia

Employment Application

Employment Application

Want to be a part of our team? Fill out the form below to apply!

Credentials Needed Before Hiring:

Upon Hiring:

State ID or Drivers License
Green Card/ USA Passport/ USA Birth Certificate
Employment verification
Interview Employee
PPD or Chest X-Ray Test
Social Security Card
Professional License Lookup
Give Orientation (Inservices on Hire)
Professional Certificate
Professional Certificate Verification
Give Employee Handbook to Employee
CPR Card
Professional License
Tax Forms Completed (W-4,W-9,VA-4)
Give Employee Pay Schedule and Time Sheet Memorandum
First Aid Card
Background Check


Download Application
  • Date Format: MM slash DD slash YYYY

  • Sworn Statement of Affirmation/Background Check Consent

  • Section s32.1-162.9:1 of the code of Virginia requires that any applicant for employment with a licensed home care organization provide the Commissioner's representative with a sworn statement or affirmation disclosing (1) whether the applicant has a criminal conviction or is the subject of any pending criminal charged within or outside The Commonwealth of Virginia, and (2) whether the applicant has been the subject of a found complaint of child abuse or neglect within or outside the Commonwealth of Virginia.
    Any person making a materially flase statement on this form shall be guilty of a Class I misdemeanor

    Further dissemination of the information provided on this form is prohibited other than to the Commissioner's representative or a federal or state authority of court as many be required to comply with an express requirement of law for such further dissemination.
  • if applicable

  • Criminal History Search Consent Form

    • Criminal homicide
    • Indecency with a child
    • Solicitation of a child
    • Arson
    • Aggravated robbery
    • Burglary & criminal trespass
    • Weapons
    • Public lewdness
    • Public indecency
    • Kidnapping & false imprisonment
    • Agreement to abduct from custody
    • Sale or purchase of a child
    • Robbery
    • Assaultive offenses
    • Theft
    • Fraud
    • Indecent exposure
    • A felony violation of a stature intended to control the possession or distribution of a substance (Virginia Controlled Substance Act)

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