Openings >> Caregiver >> Apply
Apply for Caregiver

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:Caregiver
ID:1
Department:Department 1
Location:Location 1
Contact Information
* Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Attachments
Resume:
Supported formats: Word, PDF, RTF, Text, and HTML.
  - or Upload from:
 
Cover Letter:
You can type in a Cover Letter or Copy/Paste from an existing document.
Education
List High School
Graduate
Yes
No
List College
Graduate
Yes
No
List Professional School
CNA License# and Expiration Date
List other Certifications
Additional Information
Please add any additional information necessary you feel important for us to know
General Questions
Alternate Phone Number
* Social Security Number
Driver's License Number and State issued
* Are you authorized to work in the United States for any employer?
Yes
No
* Do you have a bachelors degree?
Yes
No
* Are you 18 or older?
Yes
No
* Would you be able and willing to travel as needed by the job?
Yes
No
Do you have your own transportation
Yes
No
* Have you ever been convicted of a felony?
Yes
No
If Yes, please explain.
* What minimum salary do you require?
* What hours can you work?
Full-time
Part-time
Nights
Week-ends
Live In
* How many years experience do you have in Home Care?
0
0-1
1-2
3-5
Over 5
* Can you provide proof of any of the following Certificates (choose as many as you have)
None
CNA
HHA
CPR
First Aid
LPN
RPN
Other
ESignature
This agency performs a complete background investigation. By completing the section below you agree to allow us to obtain credit information, background information,criminal history information and a drivers license report.
* Our policy is to perform Criminal Background checks on all caregivers. By selecting "YES" in the box below entering today's date, entering your birthday and typing your name in the e-signature box,you authorize us to conduct a complete background investigation.
Yes   No
* Today's Date
* Birthday (Used only to perform criminal background)
* Electronic Signature:
Previous Employment (List up to 3)
Name of Employer
Name of last supervisor
Start Date
End Date
Complete Address
Phone Number
Reason for Leaving Job (be specific)
List all duties performed and skills used
May we contact your employer?
Yes
No
By typing your name in the box below you hereby release from all liability the company and/or person completing our Confidential Reference Request form, and authorize them to release all information regarding my employment with them.
Date
For Office Use Only
Previous Employment
Name of Employer
Name of last supervisor
Start Date
End Date
Complete Address
Phone Number
Reason for Leaving Job (be specific)
List all duties performed and skills used
May we contact your employer?
Yes
No
By typing your name in the box below you hereby release from all liability the company and/or person completing our Confidential Reference Request form, and authorize them to release all information regarding my employment with them.
Date
Office Use Only
Previous Employment
Name of Employer
Name of last supervisor
Start Date
End Date
Complete Address
Phone Number
Reason for Leaving Job (be specific)
List all duties performed and skills used
May we contact your employer?
Yes
No
By typing your name in the box below you hereby release from all liability the company and/or person completing our Confidential Reference Request form, and authorize them to release all information regarding my employment with them.
Date
Office Use Only
References
Give work or medical field references NOT relatives or personal friends
Address
Phone Number
How do you know them?
How long have you known them?
Your Comments;
Skills Assessment
Check what you have experience in
Bath
Bed Bath
Shampoo
Nail Care
Skin Care
Oral Hygiene
Shaving
Toileting/ elimination
Assist with walker
Safe ambulation technique
Range of motion exercises
Positioning of patient
Bed transfer
Making an occupied bed
wheelchair
Planning and preparing meals
Providing companionship
Transportation Assistance
Light Housekeeping
Laundry
Vacuming
Preferences (answer only if you wish)
What is your Favorite Movie?
Do you have a favorite author?
Do you have a favorite charity?
What is your favorite restaurant?
What food store do you shop at most often?
What kind of pet do you have if any?
What is your favorite holiday?
What is your favorite sports team?
Name a hobby you do or would like to do.
What is your favorite actor/actress?
Favorite place to visit?
What type of music do you listen to most often?
What is your favorite food?
Do you play an instrument?
Your Comments;
Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The Information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
I Choose Not to Respond
Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
White (Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino)
All persons who identify with more than one of the above races
I Choose Not to Respond
Veteran Status: (Please check all that apply)
Individual with a Disability
An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person's major life activities, or who has a record of such impairment.
Vietnam Era Veteran
A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred - a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5,1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
Disabled Veteran
1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability
War/Campaign/Expedition Veteran
A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized
Armed Forces Service Medal Veteran
A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty
Recently Separated Veteran
Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.

Submit
Cancel
ApplicantStack powered by Swipeclock