Apply Personal Information Date Official Use Only Position Applying For First Name * Middle Initial Last Name * Email Phone Number Alternative Phone Current Address Apartment / Unit # City * State Zip Code * Previous Address Apartment / Unit # City * State Zip Code * Emergency Contact(s)Position Applying For Phone Number 1 Phone Number 2 Phone Number 3 Have you ever submitted an application here before? Yes No Have you ever been employed here before? Yes No Have you ever been given a copy of the job description for the position for which you have applied to review Yes No Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation? Yes No Why are you interested in employment with us? Yes No Availability Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked. Available Start Date Please check all areas of availability Mornings Afternoon Evenings Overnights Weekdays Weekends Preferences Please indicate the types of services which you are willing to provide Companionship Housekeeping(dust/vacuum) Shopping/Transportation* Meal Preparation Laundry/Ironing Personal Care Activities(games/crafts) Medication Reminders Dementia/Alzheimer’s Care *In order to be able to provide transportation or run errands, you will be required to have a valid driver’s license and current auto insurance. A motor vehicle record check will be conducted and proof of insurance will be required. Are you willing to provide service to a client that smokes? Yes No Job Related Skills Describe any training or life skills you have that apply to caring for a senior Describe any work history you have that would apply to caring for a senior What do you like(or think you would like)most about working with older adults? What do you like(or think you would like) least about working with older adults? What personal rewards do you get from working with seniors? What language skills do you have? Written & Spoken Work History Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential. Most Recent Company Name Are you currently working for this employer? Yes No Address Phone Number Job Title Supervisor’s Name Duties Salary Reason For Leaving Employed From Employed To Security As a condition of employment all employees must be “Bondable” & “Insurable”. Are you at least 19 years of age? Yes No References Full Name * Mailing Address * Phone * Email * I certify that the information provided is true. I authorize background checks and agree to drug testing if required. I understand employment is at-will and can be terminated at any time. My signature confirms acceptance of these terms. Attach Certification and Licensing (accepted file formats: .doc, .docx, .pdf | Max: 10MB) * Send Message
