Apply Online with By Grace Home Care

Applicant Information
Driver License State

Pre-employement Requirements

Organization Telephone Contact Person Dates Worked May We Contact Ver
Contact Person Telephone Position/Title Dates Known Ver

Sworn Disclosure Statement
Sections 32 1-622 1:1 of the Code of Virginia requires that any person desiring work at home care organization provide the hiring facility with a sworn disclosure or affirmation disclosing any criminal convictions or pending charges, whether within or outside the Commonwealth of Virginia. The law prohibits licensed homes for adults, licensed adult care center, and home organizations from hiring individuals convicted of the following; murder, abduction for immoral purposed, assaults and bodily wounding, robbery sexual assault, arson pandering crimes against nature involving children, taking indecent liberties with children, abuse, and neglect of children, failure to secure medical attention for an injured child, obscenity offenses or abuse or neglect of an incapacitated adult. However, applicants convicted of one misdemeanor crime not involving abuse or neglect or more turpitude may be hired provided 5 years have elapsed since the conviction. Any person making false statement on this form regarding any of the above criminal offense shall be guilty upon conviction of a Class 1 misdemeanor.

Name Location Major Graduate? End Date
Name Location Graduate? End Date
Medical Form


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
Skills Questionnaire

Specialized Training

Additional Questions

Emergency Contact Information
Name Relationship Cell Phone Home Phone

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