Career -

Application Form

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability,medical condition, national origin, or marital status.

The following characters cannot be used on this form (%,&,/,?,>,<,|,{,})

Personal Information

First Name

Address 1

M.I

Address 2

Last Name

City

Home Phone

State/Prov

Cell Phone

Postal Code

How long at this address ?

Position Applying For

Work Phone

How did you hear about us?

Have you ever been convicted of a crime?

If yes, explain the nature and dates of the conviction(s)

What do you like most about working with the elderly, disabled, or convalescing client?

What do you find most challenging in this type of work?

Emergency Contact

Name

Phone

Alt Phone

Relationship

Address

City

State

Zip

Transportation

Do you have a car?

Driver’s License #

If you don’t have a car how would you get to work?

Expiration

Availability

How many hours can you work weekly?

Are you available to work nights?

Are you legally authorized to work in this country?

Would you consider live-in?

Employment Desired

Are you available to work weekends?

Available to Start Date

Are there any times you are not available to work?

Education

High School

Name

City

State/Prov

Level Completed

Degree

Major

College

Name

City

State/Prov

Degree

Major

Bus.or Trade School

Name

City

State/Prov

Degree

Major

Professional School

Name

City

State/Prov

Degree

Major

Certifications and Professional Licenses

	License number	Expiration date

Attributes

Please indicate whether you have assisted with or performed the following tasks

Companionship

Dressing/Grooming

Meal Preparation

Transferring

Light Housekeeping

Incontinence Care

Bathing/Showering

Dementia / Alzheimers

Additional Skills

Employment History (list most recent first)

Company

From

Job Title

Reason Left

Duties

Supervisor

Phone

May we contact?

Company

From

Job Title

Reason Left

Duties

Supervisor

Phone

May we contact?

Company

From

Job Title

Reason Left

Duties

Supervisor

Phone

May we contact?

Professional References (manager, supervisor, etc.)

Reference 1

Name

Relationship

Years Known

Phone

Reference 2

Name

Relationship

Years Known

Phone

Reference 3

Name

Relationship

Years Known

Phone

Reference 4

Name

Relationship

Years Known

Phone

Certification and Release Section

Date

Print your name