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(850) 329-2284
staff@availhbs.com
541 E. Tennessee Street, Suite 110, Tallahassee, Florida 32308
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Home
About
Services
Nurse Registry & In-Home Nursing Care
Homemaker & Companion Services
Disability Support Services
Community Health Worker
Transitional Housing
DCF Transitional Housing
Transition Support Services
Blog
Service Areas
Careers
Forms
New Hire Onboarding
Employees
Contractors
Client Intake Form
Medical Record Release Form
Upload Training Documents
Contact
Schedule A Consultation
Application Form
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Name
This field is for validation purposes and should be left unchanged.
Date
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Full Name
First Name
Middle Name
Last Name
Address
(Required)
Home Phone
Email
Cell Phone
Date of Birth
MM slash DD slash YYYY
Social Security Number
Your Immigration Status
Citizen
Green Card Holder
Work Visa
Are you eligible to work in the United States?
Yes
No
Gender
Male
Female
Open to Live-In Care
Yes
No
Convicted of a felony?
Yes
No
Vehicle Information
Vehicle Year
Vehicle Make
Driver's License
Yes
No
Experience
Untitled
Alzheimer's
Bed Bath
Cancer
Combative
Dementia
Dementia Experience
Gait Belt Experience
Glucose Monitor
Hospice
Hospice Experience
Hoyer Lift Experience
Incontinence
Parkinson's
Stroke
Have you had a TB test in the last 3 years?
Yes
No
Result
Positive
Negative
How did you hear about us?
Emergency Contact Name
Emergency Contact Phone
Work Preference
Date Available
MM slash DD slash YYYY
Ideal Number of Hours Per Week
Shift Availability
Monday
Morning
Afternoon
Evening
Live-In
Tuesday
Morning
Afternoon
Evening
Live-In
Wednesday
Morning
Afternoon
Evening
Live-In
Thursday
Morning
Afternoon
Evening
Live-In
Friday
Morning
Afternoon
Evening
Live-In
Saturday
Morning
Afternoon
Evening
Live-In
Sunday
Morning
Afternoon
Evening
Live-In
Education
School Name
Subject Studied
Years Attended
Location
Degree
School Name
Subject Studied
Years Attended
Location
Degree
Reference
First Reference
Name
Relationship
Phone
Years Known
Second Reference
Name
Relationship
Phone
Years Known
Describe any personal, volunteer or work related experiences that will help you in this position:
Employment History
Present/Last Employer
Employer Name
Telephone
Supervisor's Name
May we contact?
Yes
No
Address
Position Title
From Date
MM slash DD slash YYYY
To Date
MM slash DD slash YYYY
Summary of Duties
Reason for Leaving
Previous Employer
Employer Name
Telephone
Supervisor's Name
May we contact?
Yes
No
Address
Position Title
From Date
MM slash DD slash YYYY
To Date
MM slash DD slash YYYY
Summary of Duties
Reason for Leaving
Certify
Consent
By signing this application, I certify this information to be true and agree to allow the above mentioned Home Care Agency to perform a criminal history background check, at their leisure, and I give permission for them to check my references.
Full Name
Date
MM slash DD slash YYYY
Signature
Schedule Consultation
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Best Time to Call
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