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Employment Application

Apply to join Proxima Home Health Care

Your draft is saved to your account. Fields marked with an asterisk are required before submission.

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Personal information

Information provided here is used only for employment consideration.

First name *

Middle name

Last name *

Street address *

City *

State *

ZIP code *

Phone *

Email *

Emergency contact *

Relationship *

Emergency contact phone *

Emergency contact address

Second emergency contact

Relationship

Second contact phone

Second contact address

Position and availability

Tell us which role and schedule fit you best.

Position applying for *

Hours available per week

Date available

Desired pay

Employment preference

Authorized to work in the United States? *

Reliable transportation? *

Available shifts

Days Evenings Weekends Overnights

How did you hear about Proxima?

Education

List your high school, college, vocational school, or other relevant education.

School 1

School name

Location

Course of study

Diploma or degree

Years attended

School 2

School name

Location

Course of study

Diploma or degree

Years attended

Employment history

List up to four employers from the last five years, starting with the most recent.

Professional references

Provide at least two people who can discuss your job performance.

Credentials and qualifications

Summarize active licenses, registrations, expiration dates, equipment experience, and job-related skills.

Credentials and specialized skills

Can you perform the essential duties of the position, with or without reasonable accommodation?

If no, describe the requirement you cannot meet

Pennsylvania criminal-check attestation

Home health employment is subject to state-required background and registry checks. A conviction does not automatically disqualify every applicant; eligibility is assessed under applicable Pennsylvania law.

Have you been convicted of a crime in the past five years? *

Maiden names or aliases used

If yes, explain

Do not enter a Social Security number or driver's-license number here. If you are selected for hire, Proxima will collect identity and tax information through a separate protected onboarding process.

I acknowledge that Proxima may perform criminal-history and abuse-registry checks and I confirm that the information above is complete and truthful. *

Résumé or CV

Optional but recommended. Attach a PDF, DOC, or DOCX file smaller than 5 MB.

Upload résumé or CV No résumé attached.

Certification and electronic signature

I certify that this application is true and complete. I authorize Proxima to verify my employment, education, references, credentials, and background as permitted by law. I understand that false statements may disqualify me or result in dismissal, and that employment is not guaranteed for a definite period.

I have read and agree to the certification above. *

Type your full legal name as your signature *

Date *