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CONTACT
SUBMIT A REFERRAL
First name
*
Last name
*
Email
*
Phone
Multi-line address
Country/Region
*
Address
*
City
*
Zip / Postal code
*
Which position are your applying for?
*
Certified Nursing Assistant (CNA)
Caregiver / Home Care Aide
Registered Nurse (RN)
Are you at least 18 years old?
*
YES
NO
Do you have a high school diploma or GED?
*
YES
NO
Do you have a valid driver's license?
*
YES
NO
Are you CPR/First Aid certified?
*
YES
NO
Which employment type are you seeking?
*
Full-Time
Part-Time
PRN
Weekends
Overnight
Contract
Live-in opportunities (when available)
Which state are you interested and legally able to work?
*
Alabama
Georgia
In which Alabama counties are you interested in working? (select all that apply)
*
Montgomery
Autauga
Elmore
Chilton
Macon
Lee
Tallapoosa
Bullock
Dallas
Lowndes
N/A
In which Georgia counties are you interested in working? (select all that appl)
*
Fulton
DeKalb
Clayton
Cobb
Gwinnett
Douglas
Rockdale
Henry
Fayette
N/A
Are you willing to complete a drug screening?
*
YES
NO
Are you willing to undergo a criminal background check?
*
YES
NO
Can you work holidays?
*
YES
NO
Have you ever been convicted of a crime that would prevent you from working as a caregiver? (If yes, explain.)
*
YES
NO
If answered yes, please explain.
How soon can you start?
*
Month
Day
Year
Why do you want to work with GRC, and what do you hope to contribute to our team?
*
Please upload your resume.
*
Upload File
Please share two references.
*
Name
Title
Relationship
Phone Number
Email Address
Signature: I certify that all information entered into this application is honest and correct according to my knowledge.
*
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