Application Form

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - Emergency Contact

Please provide name of emergency contact.

Please provide relationship of emergency contact.

Phone number of emergency contact:

Section 2 - Transportation

Do you have dependable transportation?

Yes No

Section 3 - Availability

What are the number of hours you would like to work?

What are the times you are available to work?

Are there any times when you would not be available to work?

Section 4 - Education

What highschool did you attend? (Name, Location, Dates)

Have you attended college or been exposed to any higher education? (Name, Location, Dates)

Please list any degrees or certificates that you have earned.

Section 5 - Experience

Discuss any training or experience that you have working with the elderly.

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Section 6 - Have you assisted with any of the following?

Companionship

Yes No

Bathing/Dressing

Yes No

Light Housekeeping

Yes No

Grooming

Yes No

Incontinence

Yes No

Transfer assist

Yes No

Cooking

Yes No

Driving

Yes No

Medication Reminders

Yes No

Section 7 - Employment History

Please list 3 past employers and their phone number below.

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May we contact them? (Yes/No & Reason Why)

Section 8 - Certification and Release

I certify that I have read and understood the application and that the answers given by me to the foregoing questions and the statements made by me are complete and true for the best of my knowledge and belief. I understood 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 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.

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

Signature

Home Careolina Application Form

Personal Information

Section 1 - Emergency Contact

Section 2 - Transportation

Section 3 - Availability

Section 4 - Education

Section 5 - Experience

Section 6 - Have you assisted with any of the following?

Section 7 - Employment History

Section 8 - Certification and Release