Regal Care - Employment Application

Last Name *

First Name *

Email Address *

Phone Number

Address

Date of Birth

SSN (XXX-XX-XXXX)

Position Applying For *

Include paid and unpaid positions.

Emergency Contact

Name

Relationship

Address

Phone

Alternate Phone

Secondary Contact Name

Relationship

Phone

Alternate Phone

Medical Restrictions

Professional References

Name

Tel No

Address

Name

Tel No

Address

Background Check Authorization: I authorize Regal Care Inc. to perform a criminal background check.

Employment Agreement: I agree to at-will employment terms.

Non-Compete Agreement: I agree not to work within 50 miles for a competitor for 1 year.

Confidentiality Agreement: I will not disclose client or company information.

Non-Solicitation Agreement: I will not solicit clients or employees after termination.

Non-Driving Agreement: I do not have a valid license and will not transport clients.

COVID-19 Fit for Work: I am symptom-free and will follow PPE guidelines.

Hepatitis B Vaccination Declined: I decline the free vaccine after being informed of risks.

Influenza Vaccine Declined: I decline the flu shot.

Sexual Abuse Policy: I acknowledge receipt and understanding.

Confidentiality Statement: I agree not to disclose PHI.

Employee Handbook: I received and read it.

Non-Solicitation Agreement: I understand its terms.

State of Illinois Acknowledgement: I understand CCP rules.

Upload Supporting Documents

Resume/CV

ID Card (Front & Back)

CPR Certification