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First name*

Last name*

Date Of Birth

Month

Day

Year

SSN*

Email*

Phone*

Have you lived in North Carolina for more than 5 years?

Please provide all addresses where you have lived during the past five (5) years, starting with your current address

Address*

From

To

Address*

From

To

Address*

From

To

Address*

Position you are applying for*

Desired Pay Rate *

(Please enter your expected hourly rate or range)

Current Certifications

CPR

First Aid

Med Aide

NCI

CNA

Personal Care Aide

GED

Drivers License

QP

LCMHC

LCSW

LMFT

RN

(LCMHCA, LCSWA, etc.)

Upload Certifications

Please upload copies of all applicable certifications, including CPR, First Aid, NCI (Nonviolent Crisis Intervention), Medication Administration, CNA, or other relevant credentials. Ensure documents are current and clearly visible.

Primary Shift Preference:

First Shift (8am-4pm)

Second Shift (4pm-12 am)

Third Shift (12 am - 8am)

Other

Days Available (check all that apply):

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Other Options

Preferred Number of Hours Per Week

Full-Time (32–40 hrs)

Part-Time (16–31 hrs)

PRN / As Needed

Are you at least 18 years old*

When are you available to begin employment?

Employment History

Employer #1 Name

Job Title

Address

Phone

Employment Start Date

Employment End Date

Employer #2 Name

Job Title

Address

Phone

Employment Start Date

Employment End Date

Employer #3 Name

Job Title

Address

Phone

Employment Start Date

Employment End Date

Have you ever been convicted of a felony or misdemeanor?

Yes

No

If yes, explain (conviction does not automatically disqualify you):

Are you willing to complete (as applicable):

Criminal background check

Sex offender registry check

Driving record check

Drug screen

Reference checks

Healthcare Personnel Registry Verification

Professional References

Emergency Contact

I certify that the information in this application is true and complete. I understand that false or misleading information may result in disqualification or termination if hired.*

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I understand that employment with Skayter Dean LLC is at-will, meaning either the employee or the employer may end employment at any time, with or without cause or notice, as permitted by law.*

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I authorize Skayter Dean LLC to verify information, contact references and former employers, and obtain background screening results as required for the position.*

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Resume Upload*

Applicant Signature*

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Applicants name*

Todays Date*

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