Caregiver Application

Part 1 has been submitted. Continue your caregiver application below.

Part 2 of 4 - Education, Work History, and References

Complete Part 2 by providing information about your educational background, work history, and references. Provide work history covering at least the past five years, beginning with your current or most recent position. If you have worked for fewer than five years, provide your complete work history. Do not answer “See Résumé.” Questions marked with an asterisk are required.

All four parts of the online application must be submitted before the application is considered complete. Enter the same email address used in Part 1 so Agate can connect your submissions.

SECTION 1 - Application Identification

Email address

SECTION 2 - Educational Background

What is the highest level of education you have completed?

Name of High School, College, University, Training School, or Other Institution

City and State of Institution

Diploma, Degree, Certificate, or Program Completed

Major, Field of Study, or Area of Training

Did you graduate from or complete this program?

Yes

No

Currently Attending

Not Applicable

Graduation or Completion Date

Please list any additional education, training programs, or relevant coursework not reported in Part 1.

SECTION 3 - Work History

Please provide your current or most recent position and enough prior employment or service history to cover the past five (5) years. If your total history covers fewer than five years, provide your complete history.

Include relevant employment, independent caregiving assignments, self-employment, volunteer work, internships, or military service. Complete the requested fields rather than responding only with “See Résumé.” A résumé may be submitted as supplemental documentation.

Do you have any previous employment, independent caregiving, self-employment, volunteer, internship, or military-service history?

Yes

No

Have you ever been discharged, terminated, asked to resign, removed from an assignment, or left a position or contract without providing the expected notice?

No

Yes

A “Yes” response does not automatically disqualify you. Agate may contact you for additional information.

SECTION 4 - References

Please provide three references who can speak about your reliability, qualifications, caregiving experience, work performance, or character.

References 1 and 2 must be professional references. Reference 3 may be either professional or personal. References must not be relatives. A personal reference must not be a former employer and should have known you for at least one year.

Agate Healthcare Services may contact the references provided as part of the application review and registration process.

PROFESSIONAL REFERENCE 1

Reference’s Full Name

Reference Type

Professional

Relationship to You

Organization and Position

How long has this person known you?

Phone Number

Email Address

PROFESSIONAL REFERENCE 2

Reference’s Full Name

Reference Type

Professional

Relationship to You

Organization and Position

How long has this person known you?

Phone Number

Email Address

REFERENCE 3

Reference’s Full Name

Reference Type

Professional

Personal

Relationship to You

Organization and Position, if applicable

How long has this person known you?

Phone Number

Email Address

Information submitted through this form will be handled in accordance with Agate Healthcare Services’ Privacy Policy.

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