We are an equal opportunity contract work givers, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, medical condition, national origin, or marital status.

First Name,                                  Middle                                                 Last                                                    

Date

Street Address

Years at this address

City

State

ZIP

Home Phone

Cell Phone

SSN

Emergency Contact

Name

Phone

Address

Relationship

I am applying for a position as a

I want to work in the following areas (Please be specific) :
 

Have you ever been convicted of a felony?

 no            yes 

If yes, please provide details

Transportation:

Many caregiver positions require the caregiver to transport a client.

Do you have dependable transportation?

 no   yes 

Make and model car

License plate #

Driver license #

Auto insurance policy #

Insurance company

Insurance agent name

Insurance agent phone

Availability

Number of hours you would like to

work

Days/Times you are available to

work

Days/Times not available to work

Can you be called at the last

minute in case of emergency?

no   yes  

Comments

Education

High school

City/State

Dates

College

City/State

Dates

Other

City/State

Dates

Degrees/certificates

Special skills or courses

Experience

Discuss any training or experience working with the elderly

What would you/do you like most about working with the elderly?

What would you/do you like least about working with the elderly?

Employment History

Please go back at least five years and tell us about your work history. Use reverse side of sheet if additional space is required.

May we contact your current employer?

no    yes 

Company

From

To

Job title

Reason left

Duties

Supervisor

Phone

From

To

Job title

Reason left

Duties

Supervisor

Phone

From

To

Job title

Reason left

Duties

Supervisor

Phone

From

To

Job title

Reason left

Duties

Supervisor

Phone

Personal References

Name

Address

Relationship/Years Known

Local Phone #

Address

Relationship/Years Known

Local Phone #

Address

Relationship/Years Known

Local Phone #

Address

Relationship/Years Known

Local Phone #

Address

Relationship/Years Known

Local Phone #
 

CERTIFICATION AND RELEASE: I certify that I have read and understand the application note on page one of this form and that the answers

given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I

understand 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 company and/or its agents, including consumer reporting bureaus, to verify any

information including, but not limited to, 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.

Signature .....................................................

Date ...........................................................
 
 

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