A 5-page Word job application for caregivers and office roles at a non-medical home care agency.

For USA home care agency owners and supervisors who hire staff. Plus 1 agency instructions page to remove before use.

What’s included

1. Page 1: sections 1-3 applicant information, position desired, and work eligibility
2. Page 2: sections 4-5 education and employment history
3. Page 3: employment history continued, section 6 availability, and section 7 skills and qualifications
4. Page 4: sections 8-12 field role readiness (placement preferences, no medical questions), transportation, professional references, optional emergency contact, and background screening notice
5. Page 5: section 13 state-required notice space, section 14 applicant certification and authorization, and section 15 Agency Use Only
6. Agency instructions page, to remove before use

Add your logo and name

1. Open the Word file and replace the Your Logo Here box with your logo.
2. Replace Agency Name in the letterhead; the form body says “the Agency,” so no other name edits are needed.
3. Replace the Street Address, City, State ZIP line and the Phone, Email, Website line with your details.
4. Add any state-required notice in section 13, set the letterhead text to black, delete the instructions page, and save.

Customizable template, not legal advice; check your state’s requirements. Not a license to operate, not HIPAA software, and no medical claims. Employment rules vary. Adapt this application to federal, state, and local rules (for example, salary history and fair-chance limits) before use. Not legal advice.