Certified Nursing Assistant
(CNA I / CNA II) Employment Application

Thank you for your interest in joining the Careliant Home Care team.
Please complete all sections accurately and in full.

1 Personal Information

First Name *

Middle Name

Last Name *

Street Address *

Apt / Unit

City *

State *

ZIP Code *

Phone Number *

Email Address *

Date Available to Start *

Position Type Sought *

2 Registry & Credentials

NC Nurse Aide I Registry Number *

NC Nurse Aide II Listing Number (NCBON)

Registry / Listing Status *

Registry Listing Renewal Date

CPR / BLS Certification Expiry

Additional Certifications (e.g., Medication Aide, Alzheimer's, First Aid)

Is your registry listing free of any current substantiated findings, restrictions, or disciplinary actions? *

YesNo (please explain below)

3 Education

CNA Training Program *

Certificate / Diploma Earned *

City / State of Training Program

Graduation Year *

4 Work Experience

Years of CNA Experience *

Home Health / Home Care Experience?

Most Recent Employer

Dates of Employment

Reason for Leaving

6 Professional References

Please provide two professional references (not family members).

Reference 1 – Name

Relationship / Title

Phone / Email

Reference 2 – Name

Relationship / Title

Phone / Email

7 Background & Additional Information

Have you ever been convicted of a crime (excluding minor traffic violations)? *

Yes (please explain below)No

Are you legally authorized to work in the United States? *

YesNo

How did you hear about Careliant?

Additional Comments or Explanations

Attach Resume (optional — PDF, DOC, or DOCX) Click to upload your resume

I certify that all information provided in this application is true and complete to the best of my knowledge. I understand that false or misleading information may result in disqualification from employment or termination. I authorize Careliant Home Care, LLC to contact my references and verify the information provided, including my registry listing status. I consent to a background check as a condition of employment consideration.

Applicant Signature (type full name) *

Date *

Certified Nursing Assistant(CNA I / CNA II) Employment Application

Certified Nursing Assistant
(CNA I / CNA II) Employment Application