Internet Application Information

Current Employer Reason for Leaving

Title Dates worked from to Pay Rate

Supervisor Contact Name Telephone


Previous Employer Reason for Leaving

Title Dates worked from to Pay Rate

Supervisor Contact Name Telephone

Are you and RN LPN or a CNA , interested in Home Care or Staffing or Both

If RN/LPN interested in home care, do you have 1 yr exp Yes No and have a BLS, CPR card Yes No

If RN/LPN interested in staffing do you have 6 months exp within the past year in a facility? Yes No

Are you a Home Health Aide? (HHA) Yes No
(if yes, have you worked or completed HHA training in NY within the last two years?) Yes No Date completed:

Are you a Personal Care Aide? (PCA) Yes No
(If yes, do you have a valid PCA Certificate and have you worked on it?) Yes No
or have you completed training within the last 2 years Yes No

If you are not certified, (as above) do meet any of the following qualifications:
ACD Candidate: six months related experience (involving PCA hands-on-skills) within the last year? Yes No
(Examples of PCA hands-on skills are: helping with bathing dressing feeding walking, etc) Or related training involving instruction in PCA hands-on-skills, i.e., nurse aide training, LPN/RN training? Yes No

You can be a HHA Competency Candidate if you have been :
A Nursing Assistant with 1 full year of full time experience in a general hospital w/in past 5 years Yes No
An individual with documented HHA training and a Competency evaluation, who has not been employed as a HHA for 24 consecutive months. Yes No
An LPN or RN Student who has completed Fundamentals of Nursing Yes No
An individual with documented HHA or CNA trg and competency eval from an out of state program. Yes No

Or, are you interested in a free training PCA/HHA program? Yes No     If yes when?
Did you work with us before? Yes No
If yes, When? Why did you leave?
If No, have you applied to AC before? Yes No     If yes when?