Career Application

Name

First Middle Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How long have you lived at this address?

Social Security Number

Phone

Date of Birth

Position applied for

Director of Nursing

RN/LPN

Caregiver/CNA

Housekeeper

Cook

Hourly Rate Desired

Are you available to work weekends?

Yes

None

Some

Please indicate the times you prefer to work

Anytime

7a-3p

3p-11p

11p-7a

Please indicate the days you would prefer to work

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Employment desired

Part Time

Full Time

PRN

Are you legally allowed to work in the US

Yes

When are you available to start?

Have you ever applied here before

Yes

Have you ever been convicted of a crime?

If yes, please explain.

Have you ever worked under a different name (Maiden name or other)

If yes, what names?

Do you have any friends or relatives who work here?

If yes, who?

Where did you hear about us?

Emergency Contact

Name

First Last

Relation

Phone

Education Information

High School: Name of school, location (city, state), number of years completed, major and degree

College: Name of school, location (city, state), number of years completed, major and degree

Business or Trade School: Name of school, location (city, state), number of years completed, major and degree

Professional School: Name of school, location (city, state), number of years completed, major and degree

Personal Reference Information

Reference 1

First Last

Do not list relatives or previous supervisors

Phone number where they can be reached 9a-5p

Relationship

Reference 2

First Last

Do not list relatives or previous supervisors

Phone number where they can be reached 9a-5p

Relationship

Please summarize any additional information necessary to describe your full qualifications to be a caregiver. Please Note any experience with caregiving professionally, for your parents, spouse, children or friends.

Why do you enjoy caregiving?

Describe some of your volunteer work

Please check any certification(s) you currently posses

LPN

Certified Nursing Assistant

Work Experience

Name and Address of Present Employer

Name of Last Supervisor

Employment Dates

When did you start, when did you leave

Pay or salary

Start and Final

Phone Number

Last Job Title

Reason For leaving

please be specific

List Jobs you held, duties preformed, skills used or learned, advancements or promotions while you worked there:

May we contact your present employer?

If NO please explain why provide us with another work reference that we can contact

Name and Address of Last Employer (2)

Name and Address of Last Employer

Name of Last Supervisor

Employment Dates

When did you start, when did you leave

Pay or salary

Start and Final

Phone Number

Last Job Title

Reason For leaving

please be specific

List Jobs you held, duties preformed, skills used or learned, advancements or promotions while you worked there:

May we contact this employer?

If NO please explain why provide us with another work reference that we can contact

Skill Information

How would you rate yourself on your experience with the following aspects of caregiving?

Companionship

No Experience

Some Experience

Good Experience

Excellent Experience

Meal Preparation

No Experience

Some Experience

Good Experience

Excellent Experience

Light Housekeeping

No Experience

Some Experience

Good Experience

Excellent Experience

Bathing/Showering

No Experience

Some Experience

Good Experience

Excellent Experience

Dressing/Grooming

No Experience

Some Experience

Good Experience

Excellent Experience

Incontinence Care

No Experience

Some Experience

Good Experience

Excellent Experience

Dementia/Alzheimer's Care

No Experience

Some Experience

Good Experience

Excellent Experience

Additional Comments

Career Application

Employment Application Form

Emergency Contact

Education Information

Personal Reference Information

Work Experience

Skill Information