Job Application

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

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:	Monday (From:____To:___) Tuesday (From:____To:___) Wednesday (From:____To:___) Thursday (From:____To:___) Friday (From:____To:___) Saturday (From:____To:___) Sunday (From:____To:___)
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:	Name: Phone: Relationship:

High School:	Name: Location: Number of years completed: Degree:
College:	Name: Location: Number of years completed: Degree:
Business or Trade School:	Name: Location: Number of years completed: Degree:
Professional School:	Name: Location: Number of years completed: Degree:

1) Past Employment	Company name: Address: Name of Supervisor: Employment dates: (From – To) Pay or Salary: (Start – Finish) Contact phone #: Your Last Job Title: Reason for leaving: List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:
May we contact this employer?	Yes No
If NO, please explain why:
2) Past Employment	Company name: Address: Name of Supervisor: Employment dates: (From – To) Pay or Salary: (Start – Finish) Contact phone #: Your Last Job Title: Reason for leaving: List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:
May we contact this employer?	Yes No
If NO, please explain why:
3) Past Employment	Company name: Address: Name of Supervisor: Employment dates: (From – To) Pay or Salary: (Start – Finish) Contact phone #: Your Last Job Title: Reason for leaving: List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:
May we contact this employer?	Yes No
If NO, please explain why:

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:

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:	*A conviction will not necessarily result in the denial of employment.

Reference #1:	Name: Relationship: Company: Address: Phone: Email:
Reference #1:	Name: Relationship: Company: Address: Phone: Email:
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: