A.C.T. HOME CARE, INC. "A Caring Touch"

Continuously Seeking Ways to Improve the

Delivery of Home Care Services to our Clients

Schedule An Assessment ►

(706) 559-4432 • 1075 Gaines School Athens, GA 30605

Employment Application Form

Dear Applicant,

Thank you for applying for a position at A.C.T. Home Care, Inc. Please fill out all the necessary information requested on this form. If you have any questions regarding your application, please feel free to contact us at (706) 559-4432. A printable Employment Application (pdf) is also available if you wish to mail or fax your information.

All applications are reviewed - and subsequent staffing needs are determined - according to our current and / or projected client demand, and on an as-needed-basis. When application reviews occur, A.C.T. Home Care, Inc. will respond directly to those applicants whose experience, credentials, and applicable employment history meet the standards and requirements necessary to be employed at A.C.T. Home Care, Inc. As applying for a position does not automatically qualify you for an interview, it is the policy of A.C.T. Home Care, Inc. to seek highly qualified, responsible, and professional personnel to work with "A Caring Touch" for our clients. We will contact applicants for an interview that we feel are best suited to fulfill this most important goal of A.C.T. Home Care, Inc.

Thank you for your interest in employment at A.C.T. Home Care, Inc.


Helen Springs, RN, President
Paula Sartain, RN, BSN, Administrator

Click the 'Save' button to save any changes.

Employment Desired

Are you Employed?
If employed, may we contact your employer?
Have you ever applied/worked for A.C.T. before?

Must provide 5 years of work history. List last employer first. If not employed, provide last 5 years of location and activity.

Employer Name Dates of Employment Position Reason for Leaving
+ Add Employer
Name/Location of School Years Attended Did You Graduate?/Degree
+ Add School
Name Phone Number Personal or Professional
+ Add Reference

Please take a moment to double check the information that you entered on the previous tabs. When you have verified the information, click the "Submit Application" button below. You will not be able to update any information in your application once it has been submitted.

GCIC Consent:

Full Name (Including Maiden):

Electronic Signature


I Certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be considered grounds for dismissal. I authorize investigation of all statements contained herein and the references and employees listed to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability and damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the American with Disabilities Act (ADA) and other relevant federal and state laws.


I understand that A.C.T. Home Care, Inc. does not guarantee a full time position. All positions with A.C.T. Home Care, Inc. are PRN (as needed) positions. I further understand that I must agree to work every other weekend, as needed.

Please type your full name: