Applicant Information: First name*: Middle name: Last name*: Address*: Address Line 2: City*: State*: —Please choose an option—AlabamaAlaskaArizonaArkansasAmerican SamoaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code*: Home Phone: Mobile Phone*: Email*: Location: Hours wanted weekly*: Match Criteria: Please select checkboxes that match your skills and preferences. General Bed Bound ExperienceCancer ExperienceDementia ExperienceDiabetes ExperienceHospice ExperienceIncontinence ExperienceStroke Experience Transfers Fall Risk ExperienceGait Belt ExperienceHoyer Lift Experience Pets OK with CatsOK with Dogs Other/Misc Insured AutomobileKosher Cooking ExperienceLive-In Shifts OKOK with Client Smoking Max client weight for transfers: Education & Training: High SchoolCollege School: Degree received: Certifications and Credentials: Please check all that apply, and enter the expiration date and any notes as applicable. Type Expiration Date Notes AHCA Level II Background Alzheimer’s and dementia Certification Car Insurance Chest X-Ray CNA License CPR Certification Driver's License Drug Screen First Aid Certification HHA Certification HIV/AIDS Certification Kosher Care Experience LVN/LPN Certification Medication Administration Performance Evaluation Registered Nurse Tuberculosis Test Work Authorization Documents Employment History: Please provide your most recent positions of employment. Employer: Supervisor: Phone Number: Address 1: Address 2: City: State: —Please choose an option—AlabamaAlaskaArizonaArkansasAmerican SamoaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code: Date Employed: From: To: Employer: Supervisor: Phone Number: Address 1: Address 2: City: State: —Please choose an option—AlabamaAlaskaArizonaArkansasAmerican SamoaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code: Date Employed: From: To: Employer: Supervisor: Phone Number: Address 1: Address 2: City: State: —Please choose an option—AlabamaAlaskaArizonaArkansasAmerican SamoaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code: Date Employed: From: To: Professional References: Please provide professional references. Name: Name: Name: Phone Number: Phone Number: Phone Number: Additional Information: Please give an overview of your work history: What are your hobbies and interests? How long have you been a caregiver (for elders or disabled adults) and why do you like being a caregiver? What do you like least about being a caregiver? The best companion match for me would be some who is... How far are you willing to drive from home to a client's home? Have you ever been dismissed from a position? If yes, please explain why. Have you ever been convicted of a felony? Yes or No: How do you like to be recognized for your hard work? How did you hear about us? (Please list specific caregiver name if applicable): What is your availability and what type of shifts are you looking for (hourly, day, night, live-in, etc.)? Disclaimer: I certify that the information contained in this application is correct to the best of my knowledge. I understand that to falsify information is grounds for refusing to hire me, or discharge should I be hired. I authorize any person, organization, or company listed on this application to furnish you any and all information concerning my previous employment, education, and qualifications for employment. I also authorize you to request and receive such information. In consideration for my employment, I agree to abide by the rules and regulations of the company, which rules may be changed, withdrawn, added or interpreted at any time, at the company’s sole option and without prior notice to me. I also acknowledge that my employment may be terminated, or any offer or acceptance of employment withdrawn, at any time, or without cause, and with or without prior notice at the option of the company or myself. Attachments Supported file types: Jpeg, PNG, PDF, Doc, Docx, ODT (Max file size: 20mb) ❌ ❌ Signature* (Attach a picture of your singnature on a white paper)
