GENTLE ROOTS HOME CARE

Employment Application

800 Battery Avenue SE, Suite 300

Office #3076

Atlanta, GA 30339

Phone: 954-716-2020

Email: info@gentlerootshomecare.com

Gentle Roots Home Care is an Equal Opportunity Employer.

We hire W-2 employees only.

🔹 POSITION APPLYING FOR

Personal Care Assistant (PCA)Companion Sitter

Date of Application *

SECTION 1 – APPLICANT INFORMATION

SECTION 2 – POSITION REQUIREMENTS

For Personal Care Assistant (PCA):

Do you have one of the following?

CNA CertificationCompleted Nurse Aide Training ProgramOther DCH-Approved Healthcare Credential

License/Certification Number (if applicable)

Expiration Date

Are you CPR/First Aid Certified?

YesNo

CPR Expiration Date

For Companion Sitter:

Do you have experience with elderly, disabled, or special needs clients?

YesNo

Explain briefly:

0/500 characters

SECTION 3 – BACKGROUND & COMPLIANCE

Georgia law requires fingerprint-based background checks through GCHEXS.

Have you ever been convicted of a felony or misdemeanor (excluding minor traffic violations)?

YesNo

Have you ever been accused of abuse, neglect, or exploitation of a vulnerable adult?

YesNo

Are you willing to complete:

GCHEXS fingerprint background checkTB screeningDrug screening (if required)Orientation training

SECTION 4 – WORK HISTORY

Most Recent Employer:

Company Name

Supervisor Name

Phone

Position Held

Dates Employed From

Reason for Leaving

Previous Employer:

Company Name

Supervisor Name

Phone

Position Held

Dates Employed From

Reason for Leaving

SECTION 5 – PROFESSIONAL REFERENCES

Reference #1

Name

Phone

Relationship

Reference #2

Name

Phone

Relationship

SECTION 7 – ACKNOWLEDGMENTS

I understand that:

•Gentle Roots Home Care provides non-medical services only.
•Employees are hired as W-2 employees (not independent contractors).
•Employment is contingent upon satisfactory GCHEXS background results.
•Providing false information may result in denial or termination.
•I may be required to complete TB screening and training before hire.

By submitting this application, you acknowledge that you have read and agree to the above statements.

Next Steps

Once you have completed the application, please email the following required documents to info@gentlerootshomecare.com:

1Government-issued ID
2TB Screening (Negative result)
3CNA license or approved credential (if applying as a PCA)
4CPR/First Aid certification

After I receive your application and supporting documents, I will review everything and, if approved, send over the remaining onboarding documents along with your offer letter.

GENTLE ROOTS HOME CARE

Employment Application

🔹 POSITION APPLYING FOR

SECTION 1 – APPLICANT INFORMATION

SECTION 2 – POSITION REQUIREMENTS

SECTION 3 – BACKGROUND & COMPLIANCE

SECTION 4 – WORK HISTORY

SECTION 5 – PROFESSIONAL REFERENCES

SECTION 6 – SKILLS CHECKLIST

SECTION 7 – ACKNOWLEDGMENTS

Next Steps