Home healthcare is not just a job; it’s a calling, a commitment to enhancing the quality of life for those who may require assistance due to illness, injury, or age-related challenges. As a home healthcare giver, you’ll have the unique opportunity to forge deep connections with your clients and their families, enabling them to maintain their independence and dignity.

If you’re ready to embark on a fulfilling career that goes beyond the ordinary, we invite you to explore the opportunities at Mik-Ben Helping Hands. Join us in our mission to bring comfort, care, and compassion to those who need it most. Together, we can make a difference, one home at a time.

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Name *

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Last

Address *

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City

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Email

Gender *

Phone

SSN

Date of Birth *

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Emergency Contact

Phone

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Do you have current First Aid Certification? (State Level) *

• Yes
• No

First Aid Certification Expiry Date

Enter expiry date for your certification with date format (mm/dd/yy). Example; 12/05/2025

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Do you have current CPR Certification? (State Level) *

• Yes
• No

CPR Certification Expiry Date

Enter expiry date for your certification with date format (mm/dd/yy). Example; 12/05/2025

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Certificate/License

Expiry Date

Enter expiry date with date format (mm/dd/yy). Example; 12/05/2025

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Type of Position(s) Preferred *RNLPNCNA/PCA/HHAOther

Experience

Attachment

Click or drag files to this area to upload. You can upload up to 3 files.

Attachment: CPR Certificate, License/Certificate if appplicable, PPD/TB Test Results

SWORN STATEMENT

The law prohibits licensed Home Care Organizations from hiring or continuing to employ any individuals convicted of a barrier crime. However, applicants convicted of one misdemeanor barrier crime not involving abuse or neglect may be hired or continue to be employed if five years have elapsed since the conviction. Any person making a materially false statement on this form regarding any criminal offense shall be guilty of a Class I misdemeanor. Further dissemination of the background check information provided on this form is prohibited other than to the Commissioner's representative or a federal or state authority or court as may be required to comply with an express requirement of law for such further dissemination

Have you ever been convicted of a law violation(s) but excluding offenses committed before your eighteenth birthday that were finally adjudicated in a juvenile court or under a youth offender law? *

• Yes
• No

If "Yes", list all and explain

Are you the subject of any pending criminal charges? *

• Yes
• No

If "Yes", explain

AFFIRMATION

I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained in this application, as required. Additionally, I authorize former employers, references and any other individual/organizations to provide information to Mik-Ben Helping Hands and I hereby release and discharge any of the above and Mik-Ben Helping Hands from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary I understand that failure to meet any medical and/or health requirements for the position may prevent my employment with the Agency. I also understand that employment, for certain positions, may be conditional upon successful completion of a substance abuse screening test and a criminal background check I further understand that, if hired, I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States

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Applicant's Signature *

Clear Signature

Date *

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