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Job Application
Information Sheet
Step
1
of
4
25%
Date
MM slash DD slash YYYY
Name
First
Middle
Last
Address
City
State
Zip
Email Address
Date of Birth
MM slash DD slash YYYY
Social Security #
Driver's License #
Are you legally authorized to work in the USA?
Yes
No
Are you at least 18 years old?
Yes
No
If not, do you have a work permit?
Have you been convicted of or pleaded no contest to a felony within the last five years?
Yes
No
If yes, please explain
Emergency Contact
Name
Relationship
Home #
Cell #
Allergies
CAREGIVER PROFILE & AVAILABILITY
Date
MM slash DD slash YYYY
Gender
Male
Female
Name
City
Phone Contact
2nd #
Titles
RN
LPN
CNA
HHA
Days/Hours Available
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Live-in
Yes
No
Holidays
Yes
No
Emergency
Yes
No
Weekend Relief Live-in
Yes
No
Weekend Relief Hourly
Yes
No
Geographical Work Area
Driver License
Yes
No
Car
Yes
No
Alzheimer’s Care Experience
Yes
No
Hospice Care Experience
Yes
No
Other language
Are you familiar with kosher food?
Yes
No
Can you work with pets in the home?
Yes
No
Can you use Hoyer Lift?
Yes
No
What type of patients have you worked with in the past?
EDUCATION
Check your present year in School
High School
3
4
College
1
2
3
4
Graduate
1
2
3
Education, Training and Skills
Vocational Business, Other
School Attended
Name & Location
Major
Degree
High School
School Attended
Name & Location
Major
Degree
College/University
School Attended
Name & Location
Major
Degree
College/University
School Attended
Name & Location
Major
Degree
EMPLOYMENT HISTORY
List all work experience in the last 7 years, beginning with your
current or most recent position.
Company Name 1.
from
MM slash DD slash YYYY
to
MM slash DD slash YYYY
Address: (Street, City, State, Zip)
Name of Supervisor
Phone #
Title
Reason for leaving
Description of responsibilities
Company Name 2.
from
MM slash DD slash YYYY
to
MM slash DD slash YYYY
Address: (Street, City, State, Zip)
Name of Supervisor
Phone #
Title
Reason for leaving
Description of responsibilities
Company Name 3.
from
MM slash DD slash YYYY
to
MM slash DD slash YYYY
Address: (Street, City, State, Zip)
Name of Supervisor
Phone #
Title
Reason for leaving
Description of responsibilities
May we contact the employers listed above? If not, indicate the one(s) you do not wish us to contact.
References
Please list three individuals able to give character references.
Name 1.
Work Phone
Home #
Address (Street, City, State, Zip)
Occupation
Relationship to Applicant
Name 2.
Work Phone
Home #
Address (Street, City, State, Zip)
Occupation
Relationship to Applicant
Name 3.
Work Phone
Home #
Address (Street, City, State, Zip)
Occupation
Relationship to Applicant
Consent
I certify that the information contained in this application is true and complete. I understand that false information may be grounds immediate termination of contract at any point in the future if I am contracted. I authorize the verification of any or all information listed above.
Signature
Date
MM slash DD slash YYYY
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