Online Application

We are always interested in hearing from experienced, caring, friendly and dependable people with a calling to provide superior non-medical, in-home care to senior citizens. Often, our caregivers become a close friend or at times like a surrogate family member in assisting their client’s needs. It is rewarding to know that you are an important part of enabling someone to remain living with dignity in the comfort of their own home.

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.

Name *	:
Email *	:
Phone *	:
Street *	:
City *	:
State *	:	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code *	:
SSN *	:
Emergency Contact
Name *	:
Phone *	:
Address *	:
Relationship *	:
Employent Details
Position Applied for *	:
Ever been convicted of a felony? *	:	No Yes
If yes, please provide details	:
Transportation
Many caregiver positions require the caregiver to transport a client.
Have dependable transportation?	:	No Yes
Make and model car	:
License plate #	:
Driver license	:
Auto insurance policy	:
Insurance company	:
Insurance Agent Name	:
Insurance Agent Phone	:
Availability
Hrs you would like to work *	:
Times you are available to work *	:
Any times not available to work *	:
Contact you in case of emergency? *	:	No Yes
Comments *	:
Education
High School *	:
City/State *	:
Date *	:
Collage *	:
City/State *	:
Date *	:
Others	:
City/State	:
Date	:
Degrees/Certificates	:
Special Skills or Courses	:
Experience
Discuss any training or experience working with the elderly
What would you like most about working with the elderly?
What would you like least about working with the elderly?
Skills
Please indicate whether you have assisted with or performed the following tasks for seniors.
Companion-ship No Yes Vacuuming No Yes Bathing/ dressing No Yes Dusting No Yes Grooming No Yes Clean bathrooms No Yes Incontinence No Yes Clean kitchen No Yes Transfer assist No Yes Bed linen changes No Yes Laundry No Yes Grocery shopping No Yes Cooking No Yes Driving No Yes Medication reminders No Yes
Employment History
Please go back at least five years and tell us about your work history. Use reverse side of sheet if additional space is required.
May we contact your current employer? * : No Yes
Current Employer
Company *
Duration *
Job title *
Reason left *
Duties *
Supervisor *
Phone *
Previous Employer 1
Company
Duration
Job title
Reason left
Duties
Supervisor
Phone
Previous Employer 2
Company
Duration
Job title
Reason left
Duties
Supervisor
Phone
Business Reference
Reference 1
Name
Address
Relationship/Year Know
Local Phone
Reference 2
Name
Address
Relationship/Year Know
Local Phone
Reference 3
Name
Address
Relationship/Year Know
Local Phone
Personal Reference
Reference 1
Name
Address
Relationship/Year Know
Local Phone
Reference 2
Name
Address
Relationship/Year Know
Local Phone
Reference 3
Name
Address
Relationship/Year Know
Local Phone
CERTIFICATION AND RELEASE: I certify that I have read and understand the application note on page one of this form and 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 and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
Signature		Date * :
Offical Use
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