Job Application: Certified Nursing Assistant (CNA), Home Health Aides & Companions

Title: Certified Nursing Assistant (CNA), Home Health Aides & Companions

Fields marked with an asterisk (*) must be filled out before submitting.

Personal Information

First Name *
Last Name *
Address
City
Zip Code
Country
How long at this address?
Email Address *
Home phone
Cell phone *
Social Security No.: *
Date of Birth: *
Have you ever applied here before? Yes
No
Are you legally authorized to work in the US? Yes
No
Are you available to work weekends? Yes
Some
None
Are you available to work nights? Yes
Some
None
Please indicate the days and times you are available to work:
Salary range desired:
How many hours can you work weekly?
Would you consider live-in care? Yes
No
Employment desired: Part-time only
Full or Part-time
Full-time only
When are you available to start work?
Where did you hear about us?
Have you ever worked under a different name? Yes
No
If YES, what was it and what was the reason?
Do you have any relatives or friends that work for the Company? Yes
No
If YES, what is their name?
In case of an emergency, please contact:

Education Information

High School:
College:
Business or Trade School:
Professional School:

Work Experience

Please list at least 2 of your work experiences for the past five years beginning with your most recent job held. If you were self-employed, give company name.

1) Past Employment
May we contact this employer? Yes
No
If NO, please explain why:
2) Past Employment
May we contact this employer? Yes
No
If NO, please explain why:
3) Past Employment
May we contact this employer? Yes
No
If NO, please explain why:

Skill Information

How would you rate yourself on your experience with the following aspects of care giving? (1=None, 2=Some, 3=Good, 4=Excellent)

Companionship
Meal Preparation
Light Housekeeping
Bathing / Showering
Dressing / Grooming
Transferring
Incontinence Care
Dementia / Alzheimers Care
Please check any certifications you currently have: Certified Nursing Assistant
Certified Medicine Aide
Geriatric Nursing Assistant
Medication Technician
CPR Certification
First Aid Certification
Additional Comments:

Driving Information

Do you have a valid drivers license? Yes
No
Drivers License No:
State of Issue:
Expiration Date:
Have you had any accidents during the past three years? Yes
No
How many?
Have you had any moving violations during the past three years? Yes
No
How many?
Have you ever been convicted of a crime Yes
No
If yes, explain number of conviction(s), nature of offenses(s) leading to convictions(s), how recently such offense(s) was/were committed, sentence(s) imposed and type(s) of rehabilitation:

Personal Reference Information

List two personal references. Do NOT include relatives or previous supervisors.

Reference #1:
Reference #1:
An application form sometimes makes it difficult to adequately summarize a complete background. Use the space below to give any additional information to describe you qualifications. Please note any experience with care giving professionaly, for parents, spouse, children and/or friends.
Why do you enjoy care giving?
Describe some of your volunteer work:
Upload Resume if available: