Job Application

1. Position Information

Today's date

Position desired *

Date you can start *

Salary / wage desired

Preferred employment status *

Hours available *

2. Background Check Attestation

I understand that, consistent with Massachusetts law, Next Chapter Home Agency LLC does not ask about criminal history on this application. If I receive a conditional offer of employment, I authorize the Agency to request my Criminal Offender Record Information (CORI) and related background checks, and I will receive a copy of the Agency's CORI policy and an opportunity to dispute any record before a decision is made. I certify that the information in this application is true and complete.

Type your full name to sign *

3. Personal Information

First name *

Middle name

Last name *

Street address *

Address line 2

City *

State *

ZIP *

Primary phone *

Email *

Emergency contact name *

Relationship

Emergency contact phone *

Are you legally authorized to work in the United States? *

Yes

No

4. Application History

Have you previously been employed by Next Chapter Home Agency? *

Yes

No

Have you ever worked or held a license under another name? *

Yes

No

Do you have relatives currently working for the agency? *

Yes

No

Has a license, registration, or certification of yours ever been suspended, revoked, or placed on probation? *

Yes

No

Have you ever been barred from a federally funded program (e.g. Medicare/Medicaid exclusion list)? *

Yes

No

Are you a veteran? (optional)

Yes

No

5. Skills & Qualifications

Last level of education completed *

Relevant training & certifications

6. Health Care & Home Care Experience

Have you worked in home care or home health before? *

Yes

No

Do you have experience supporting older adults or people with disabilities? *

Yes

No

Have you had a gap of two or more years in health/home care employment? *

Yes

No

Massachusetts health care license(s) held *

License number

Additional relevant experience

7. Employment History

Most recent employer *

Employer name

Employer phone

Employer address

Position held

Date started

Date ended

Duties performed

Are you still employed there?

Yes

No

Supervisor's name

May we contact them?

Yes

No

Reason for leaving

Previous employer

Employer name

Employer phone

Employer address

Position held

Date started

Date ended

Duties performed

Supervisor's name

May we contact them?

Yes

No

Reason for leaving

8. References

Name *

Phone *

How you know them

Name

Phone

How you know them

Name

Phone

How you know them

9. How did you hear about us?

Resume & Availability

Resume

Certifications & licenses (optional)

CNA, HHA, PCA, Homemaker, CPR/First Aid, driver's license, or other training certificates. Up to 6 files, 8 MB each (PDF, photo, or Word).

Anything else we should know

1. Position Information

2. Background Check Attestation

3. Personal Information

4. Application History

5. Skills & Qualifications

6. Health Care & Home Care Experience

7. Employment History

Most recent employer *

Previous employer

8. References

9. How did you hear about us?

Resume & Availability

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