Apply Online with 365 Care, LLC

Applicant Information
Driver License State
Job History
Organization Telephone Contact Person Dates Worked May We Contact Ver
Contact Person Telephone Position/Title Dates Known Ver

Criminal History

Name Location Major Graduate? End Date
Name Location Graduate? End Date

Live-Ins - Being a Live-In means several consecutive days of care where the Caregiver stays at the care recipient's home for the entire number of days.
Skills and Preferences

Specialized Training
Additional Questions
Emergency Contact Information
Name Relationship Cell Phone Home Phone

I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions, or misrepresentation of facts will result in rejection from this application and/or discharge at any time during employment period. I authorize 365 Care, LLC to verify any and all information contained within this application, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment.

I agree not to do business directly with any individual or business entity that 365 Care, LLC has introduced to me or by entering into employment with such individuals or businesses.

365 Care, LLC is registered under the provisions of M.G.L. c.6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants and current licensees. As a prospective or current employee, subcontractor, volunteer, license applicant or current licensee, I understand that a CORI check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to 365 Care, LLC to submit a CORI check for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I understand that within this one year period of time the 365 Care, LLC may conduct subsequent CORI checks for my personal information. I may withdraw this authorization at any time by providing 365 Care, LLC with written notice of my intent to withdraw consent to a CORI check. By signing this application, I provide my consent to a CORI check and affirm that the information provided to process the CORI check is true and accurate.