Registered Nurse
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 Licensure & Credentials

NC RN License Number *

License Expiration Date *

License Status *

CPR / BLS Certification Expiry

Additional Certifications (e.g., CHPN, IV Therapy, Wound Care)

Is your license free of any current disciplinary actions, restrictions, or investigations? *

YesNo (please explain below)

3 Education

Nursing School / Program *

Degree / Diploma Earned *

City / State of School

Graduation Year *

4 Work Experience

Years of RN 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. I consent to a background check as a condition of employment consideration.

Applicant Signature (type full name) *

Date *

Registered NurseEmployment Application

Registered Nurse
Employment Application