Apply to Agate's Caregiver Registry
Part 3 has been submitted. Continue your caregiver application below.
Complete Part 4 by uploading any supporting documents currently available to you and completing the final application acknowledgments and signature. Supporting-document uploads are optional unless Agate has specifically instructed you otherwise. 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 the previous parts so Agate can connect your submissions.
Do not enter or upload your Social Security number, Social Security card, banking information, direct-deposit information, or completed tax forms through this form. If additional sensitive information is required, Agate will provide instructions for submitting it through a designated secure method.
Upload any supporting documents currently available to you. Providing available documents now will help expedite the review and registration process.
If a document is not currently available, you may still submit Part 4.
Files should be current, complete, and legible and should show all relevant names, dates, expiration dates, and issuing organizations.
ADDITIONAL REGISTRATION INFORMATION
After reviewing your application, Agate may request additional identity, screening, tax, insurance, health, contractual, or registration information and will provide instructions for submitting it. This application does not replace any separate authorization, agreement, tax form, screening document, or other item required before registration.
I certify that the information I provided in Parts 1, 2, 3, and 4 of my Caregiver Application is accurate, complete, and current to the best of my knowledge. I understand that intentionally false, misleading, or omitted information may affect my eligibility for registration or caregiver referrals.*
I certify that any documents I submitted are authentic, complete, and unaltered except for redactions made in accordance with Agate’s instructions to protect sensitive information.*
I authorize Agate Healthcare Services to verify the education, work history, references, licenses, certifications, insurance coverage, and other qualifications or documents identified in my application. I understand that Agate may request additional information or a separate authorization when required for a particular verification or screening process.*
I agree to notify Agate Healthcare Services if information provided in my application changes, including my contact information, availability, service area, license or certification status, insurance coverage, health-document status, or eligibility to provide caregiver services.*
I acknowledge that Agate Healthcare Services is a Florida-licensed nurse registry that refers independent caregivers. I understand that submitting an application or becoming registered does not create an employer-employee relationship with Agate. If registered, I may decide whether to accept or decline each referral opportunity, subject to the applicable agreements.*
I understand that submitting all four parts of the application does not guarantee registration, caregiver referrals, a particular schedule, or any minimum amount of referral activity. Additional review, verification, screening, documentation, agreements, and registration requirements may apply.
I consent to the use of my electronic signature for this application. I understand that my electronic signature is intended to have the same effect as my handwritten signature.
Use your mouse, trackpad, or touchscreen to draw your signature. Downloading a copy is optional and does not submit the form. Select “Submit Part 4” when you are ready.
Information submitted through this form will be handled in accordance with Agate Healthcare Services’ Privacy Policy.