Employment Application

ATTENTION: There are two pages to this application. Make sure to fill out and submit BOTH pages. Thank you.

Personal Information:

Date:

5/3/2024

*First Name:

*EMail:

Middle Init:

*Re-Enter EMail:

*Last Name:

Home Phone No:

Alias:

*Mobile No:

*D.O.B.

Mobile accepts texts

*Social Security No:

- -

*Current Address:

Address Line 2:

*City:

*State:

*Zip:

How long have you lived at this address?

*Are you legally eligible for employment in the US? Yes No

Employment Information:

Position Appling for:

Referred By:

Type of employment desired:

Wage desired:

per hour

*Are you willing to work overtime, if required?: Yes No

*Are there any shifts or hours that you cannot work? Yes No

If yes to above, please identify?

*Are you able & willing to perform job related functions with or without accommodation? Yes No

*Have you ever applied for a position with this company before? Yes No

If yes, when?

*Have you ever been convicted of a felony or a misdemeanor? Yes No

If yes, state the date and places where the charges occured?
(Please note that answering yes will not automatically disqualify you for employment)

*Are you presently employed? Yes No
*If yes, may we contact your present employer? Yes No

Education:

	Years Completed	*Did you graduate?	Degree earned (major)
High School:		Yes No
College:		Yes No
Graduate School:		Yes No
Trade, Business, or Correspondence School:		Yes No

List any extracurricular activities, awards, scholarships, or clubs that you were involved in which might be related to the position for which you are applying

Do you have any experience as a homemaker/companion/home health aide? Check all that apply.

With an Agency

Personal Experience

Private Duty

Do you have any experience working in an assisted living facility or nursing home? Check all that apply.

(ALF) assisted living facility

Nursing home

Do you have any physical limitations that may hinder your ability to work with a client? Please explain.

Do you have any knowledge or experience with someone who has Alzheimer’s/Dementia? Please explain.

Are you willing to work a facility?

How do you feel about working in an assisted living facility or nursing home? Please explain.

Can you cook?

Do you enjoy cooking?

What are your personal strengths that will contribute to your success as a caregiver/ companion/home health aide?

Check all languages that you speak and understand

English Spanish Creole Russian Polish Hungarian Other

Check all that apply

I have my own transportation
I am willing to transport clients in my vehicle
I am willing to transport clients in their vehicle
I am willing to work with a smoker

I am willing to work with dogs
I am willing to work with cats
I am willing to work with any pets
I am willing to work with male clients
I am willing to work with female clients

Availability