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Employment Application



To become a care provider, please fill out the form completely.
Personal Information


First Name: Last Name:
SSN: Email:
Address:
City: State:
Country: Zip:
Home Phone: Cell Phone:


Background


Is English your first language? Yes No
What other Languages do you speak fluently?
Have you ever been convicted of a crime? Yes No
If yes please explain below.
A "yes" answer will not automatically disqualify you from employment but will be considered only as it is relevant to employment and compliance with state law.
Are you 18 years or older? Yes No
Do you smoke? Yes No
Are you a U.S Citizen? Yes No
If not, are you a resident alien? Yes No
Alien registration Number:


Education


High School Completed: Yes No
Location
College Completed: Yes No
Location:
Degree Earned:


Work Experience


Years of professional elder care:
Type of Experience:
Explain your experince with the following:
Companion Care:
Housekeeping (duties, vacuming etc.)
Cook/Prepare Meals (what foods you can cook):


Work Preferences


Will you accept (check all that apply): FT PT Temporary
  Days Evenings Nights Weekends
Can you work with clients who smoke? Yes No
Are you willing to work in a home with pets? Yes No
If so, are you willing to help with pet care? Yes No
Available for emergency/Short term? Yes No


Employment History:


Employer 1
Name:  
City: State:  
Zip:  
Position:  
From: To:  
Phone Number:  
Starting Salary: Ending Salary:  


Describe Job Responsibilities:


Reason for leaving:


May we contact Employer? Yes No  


Supervisors Name & Phone Number:


Employer 2
Name:  
City: State:  
Zip:  
Position:  
From: To:  
Phone Number:  
Starting Salary: Ending Salary:  


Describe Job Responsibilities:


Reason for leaving:


May we contact Employer? Yes No  


Supervisors Name & Phone Number:


CERTIFICATION AND RELEASE:   I certify that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer- reporting bureaus, to verify any information including, but not limited to, criminal history.

CHECK HERE IF YOU AGREE: