GoldMinerz Home Care LLC
☎ 732-860-1883 Care Consultation
← Back to Careers
GoldMinerz Home Care LLC

GOLDMINERZ HOME CARE LLC

260 Washington Avenue  |  Carteret, NJ 07008
APPLICATION FOR EMPLOYMENT
Caregiver / Certified Homemaker-Home Health Aide (CHHA)
COMPASSIONATE CARE. EXCEPTIONAL PEOPLE.
Where Compassion Is Worth Gold.

Please complete all applicable sections. GoldMinerz Home Care LLC is an equal opportunity employer. Employment decisions are made without unlawful discrimination. Completion of this application does not create a contract of employment or guarantee employment.

1. APPLICANT INFORMATION

2. POSITION INFORMATION

3. PROFESSIONAL LICENSE & CREDENTIAL INFORMATION

Professional Discipline Disclosure:
Has any professional certification, license, or registration you hold ever been suspended, revoked, restricted, placed on probation, surrendered, or otherwise disciplined by a licensing authority?
You may attach digital copies of your New Jersey CHHA license and your resume (PDF, Word, or Image). Max 5MB each.
COMPASSIONATE CARE. EXCEPTIONAL PEOPLE.  |  Where Compassion Is Worth Gold. • Page 1

4. EDUCATION & PROFESSIONAL TRAINING

School / Institution City / State Program / Major Degree / Diploma Graduation Date

5. EMPLOYMENT HISTORY

List your most recent employment first. Include sufficient employment history to demonstrate your caregiving and home care experience. Attach an additional page if necessary.

Employer 1 (Most Recent) Current or Most Recent
Employer 2
COMPASSIONATE CARE. EXCEPTIONAL PEOPLE.  |  Where Compassion Is Worth Gold. • Page 2
Employer 3

6. CAREGIVER / CHHA EXPERIENCE

Do you have prior experience working as a caregiver, home health aide, or CHHA?
Do you have experience providing personal care, homemaker, or home care services?
Do you have experience assisting clients with activities of daily living (ADLs)?

7. PROFESSIONAL REFERENCES

Name Professional Relationship Organization Phone Email

8. HEALTHCARE PROGRAM / PROFESSIONAL DISCLOSURES

Answer the following questions to the best of your knowledge. A 'Yes' response does not automatically disqualify an applicant; additional information may be requested when relevant and legally permissible.

1. Are you currently excluded, suspended, debarred, or otherwise ineligible to participate in Medicare, Medicaid, or another federal or state healthcare program?
2. Are you currently subject to a pending professional certification, licensing, or disciplinary action that could affect your ability to perform the duties of this position?
COMPASSIONATE CARE. EXCEPTIONAL PEOPLE.  |  Where Compassion Is Worth Gold. • Page 3

9. EMPLOYMENT ELIGIBILITY & ESSENTIAL FUNCTIONS

Are you legally authorized to work in the United States?
Will you now or in the future require employment sponsorship?
Are you able to perform the essential functions of the Caregiver / CHHA position, with or without reasonable accommodation?

10. APPLICANT AUTHORIZATION

I authorize GoldMinerz Home Care LLC to verify information provided in this application, including my employment history, education, professional certifications and credentials, and professional references, as permitted by law. I authorize persons and organizations contacted for these purposes to provide relevant information concerning my qualifications and employment history, subject to applicable law.

I understand that any consumer report or background report governed by the Fair Credit Reporting Act (FCRA), if requested by GoldMinerz Home Care LLC, will be handled through a separate disclosure and authorization process as required by law.

11. APPLICANT CERTIFICATION

I certify that the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that material misrepresentations or omissions may result in withdrawal of an employment offer or other employment action, consistent with applicable law. I understand that this application is not an employment contract and does not alter the at-will nature of employment where applicable.

✒ Sign here using mouse or fingertip
FOR AGENCY USE ONLY
This section is completed by GoldMinerz Home Care LLC office management during review.
Date:
COMPASSIONATE CARE. EXCEPTIONAL PEOPLE.  |  Where Compassion Is Worth Gold. • Page 4

Please review all information before submitting. Once submitted, your completed employment application will be sent directly to the GoldMinerz Home Care LLC hiring team.