CareLuxe Solutions

Application for Employment

Personal Information

Complete all required fields marked with a red *.

First name*

Middle name

Last name*

Email*

Phone*

Street address*

City*

State*

ZIP code*

Date of birth*

Social Security number*

Driver's License / ID Number*

Driver's License / ID state*

Position Details

Tell us what role and schedule you are interested in.

Position applied for*

Preferred contact method

Available start date

Desired schedule

Preferred service area / counties

Education

Education and training details are optional.

Highest level of education completed

School name

Program / major

Year completed

Additional training / certifications

Job History

Tell us about your most recent job. Optional.

Employer name

Position / title

Start date

End date

Reason for leaving

May we contact this employer?

YesNo

References

Provide two references with name, phone, and relationship.

Reference 1

Name

Phone

Relationship

Reference 2

Name

Phone

Relationship

Electronic Signature

Sign and date your application electronically.

Electronic Records and Signatures Disclosure

Please read this disclosure carefully before signing. By signing electronically, you agree to use electronic records and signatures for this CareLuxe Solutions form, with the same legal effect as a handwritten signature on paper.

Legal effect: Under the Pennsylvania Electronic Transactions Act (73 P.S. §§ 2260.101 et seq.) and the federal E-SIGN Act (15 U.S.C. §§ 7001 et seq.), an electronic signature has the same legal effect, validity, and enforceability as a handwritten signature, and an electronic record satisfies any law that requires a record to be in writing.
Right to a paper process: You may request a paper-and-pen process, or a paper copy of any record CareLuxe Solutions provides electronically, by contacting CareLuxe Solutions before submitting this form. Requesting a paper copy will not, by itself, withdraw your consent to use electronic records. Contact CareLuxe Solutions.
Right to withdraw consent: You may withdraw your consent for future electronic records at any time by contacting CareLuxe Solutions. Withdrawal does not affect the legal validity or enforceability of records you have already signed electronically.
Keeping your contact information current: Keep your contact information current by emailing the address shown on the CareLuxe Solutions website or in your confirmation email so we can deliver records to you.
Hardware and software requirements: To access, print, save, and retain the records you sign here, you need a current desktop or mobile web browser with JavaScript and cookies enabled, an active internet connection, an email address that can receive messages from CareLuxe Solutions, and the ability to view PDF documents.
Record retention: After submission you will receive a copy of the signed record. CareLuxe Solutions retains a tamper-evident copy of the signed record together with the date and time of signing, the browser used, and a hashed record of the network address used to sign.
How your signature is attributed to you: Your signature is logically associated with this record by your typed legal name, the time of signing, and the audit metadata captured at submission, and it is attributable to you under 73 P.S. § 2260.305.

Full legal name*Signature date*

Your electronic signatureSigned by —May 26, 2026

I have read the Electronic Records and Signatures Disclosure above and consent to use electronic records and signatures for this CareLuxe Solutions form, as permitted by the Pennsylvania Electronic Transactions Act and the federal E-SIGN Act.*
I understand that providing my signature in this form is my electronic signature and is intended to have the same legal effect as my handwritten signature on paper.*

By signing, you authorize CareLuxe Solutions to capture the date, time, browser, and a hashed network address as audit data so this signature remains legally enforceable.

Prefer to sign on paper? Contact CareLuxe Solutions through the contact page before submitting this form to request a paper-and-pen process.

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