Compassionate In-Home Care in Reston for Seniors by Experts

Employment Application

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Application Received

Thank you for applying to Quality Life Home Care LLC.

We have successfully received your information and attached documents. Our hiring team will review your application and contact you if your qualifications match our current needs.

I. Applicant Information

Full Legal Name

Current Residential Address

City

Zip Code

Primary Phone

Email Address

Date of Birth (Must be 18+)

Social Security (Last 4 Digits ONLY)

Security Notice: To protect your identity, please provide only the last 4 digits here. We will request the full number in person during the interview process.

Are you legally authorized to work in the United States?

Yes No

II. Professional Licensure & Certification

CNA Certificate Number

Expiration Date

Has your professional license or certification ever been suspended, revoked, or subject to disciplinary action?

Yes No

Have you ever had a finding of abuse, neglect, or misappropriation of property entered against you?

Yes No

III. Criminal History Record

Have you ever been convicted of, or pled guilty or no contest to, a violation of the law in any jurisdiction?

Yes No

Virginia Code Compliance: Do NOT disclose information regarding arrests, charges, or convictions for simple possession of marijuana that have been sealed, expunged, or otherwise protected from disclosure under the Code of Virginia § 19.2-389.3.

If you answered "Yes" to the above, please provide dates and details:

IV. Clinical Skills Assessment

Competency	1No Experience	2Some Experience	3Expert
PERSONAL CARE (ADLs)
Bathing & Hygiene
Toileting / Incontinence
MOBILITY & SAFETY
Transfers (Bed/Chair)
Mechanical Lift (Hoyer)
CLINICAL SUPPORT
Vital Signs
Alzheimer's / Dementia

V. Schedule Availability

Earliest Start Date

Desired Hours Per Week

Preferred Shifts (Select all that apply)

Mornings (7am - 3pm) Evenings (3pm - 11pm) Overnights (11pm - 7am) Weekends

VI. Employment Experience

Most Recent Employer

Previous Employer

VII. Virginia Sworn Disclosure Statement

Pursuant to § 32.1-162.9:1 of the Code of Virginia.

1. Have you ever been convicted of a crime within or outside of Virginia?

Yes No

2. Are you currently the subject of any pending criminal charges?

Yes No

3. Have you ever been the subject of a founded complaint of child abuse or neglect?

Yes No

VIII. Applicant Statement & Authorization

Prohibition on Barrier Crimes: I understand that Quality Life Home Care LLC is prohibited by Virginia law from hiring any individual convicted of a Barrier Crime.

Affirmation: I affirm that the information provided in this application is true, correct, and complete. I understand that knowingly making a false material statement on this form constitutes a Class 1 Misdemeanor under Virginia law.

Electronic Signature (Please type your full legal name)

Date of Signature

Physical Capability Attestation

I attest that I am physically capable of performing the essential duties of this position, including lifting up to 50 lbs.

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