First Name
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Last Name
*
Address
*
City
*
State
*
Postal code
*
Phone
*
Email
*
Do you have a car that you drive to and from work?
*
Do you have a car that you drive to and from work?
YES
NO
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What days are you available to work?
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What days are you available to work?
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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What shifts are you available to work? (Check all that apply)
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Live-in (24 hours)
Morning 6 AM - 12 PM
Afternoon 12 - 4 PM
Evening 4 - 10 PM
Overnight 10 PM - 6 AM
How did you hear about us?
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Special Skills
Why do you want to work with Actify Home Care?
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