CHHC Application for Employment
Pre-employment Questionnaire Equal Opportunity Employer. Please fill in your details below.
Personal Information
First Name
*
Last Name
*
SSN/TIN
*
Date of Birth
*
-
Month
-
Day
Year
Date
Present Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email Address
*
How did you hear about us?
*
Emergency Contact Name (1)
*
First Name
Last Name
Emergency Contact Number
*
-
Area Code
Phone Number
Relationship
*
Emergency Contact Name (2)
First Name
Last Name
Emergency Contact Number
-
Area Code
Phone Number
Relationship
Employment Desired
Position Desired
*
Date you can start
Salary Desired/Hourly
Are you currently employed?
*
Yes
No
Availability
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Type of Care preference
*
Driving Companion Care
Shared-setting Care
Overnight Care
Flexible Hourly Vare
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Next
General Information
Subject of Special Study/Research Work
Driving
*
Yes
No
U.S Military of Naval Service?
*
Yes
No
Upload your CV (Resume)
Upload a File
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of
Upload your GOVERNMENT ISSUED ID (e.g License)
*
Upload a File
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of
Latest TB TEST results
*
Upload a File
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of
Date
-
Month
-
Day
Year
Date
Screening Questions:
Are you authorized to work in the U.S.?
*
Yes
No
Choose not to answer
Do you have a caregiving experience?
*
Yes
No
If Yes, how many years?
Name of previous employer (1) (over the last five years)
*
(COMPANY NAME, CONTACT NUMBER)
Dates of Employment (From – To)
*
May we contact your previous employers or references?
Yes
No
Name of previous employer (2) (over the five years)
(COMPANY NAME, CONTACT NUMBER)
Dates of Employment (From – To)
May we contact your previous employers or references?
Yes
No
Name of previous employer (3) (over the last five years)
(COMPANY NAME, CONTACT NUMBER)
Dates of Employment (From – To)
May we contact your previous employers or references?
Yes
No
Do you have the latest Flu shot?
*
Yes
No
DO you have the Covid-19 vaccine?
*
Yes
No
Do you have CPR/ BLS/ First-aid Training Certificate?
*
Yes
No
Training Certificate
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of
Do you have the following license or certification: Home Care Aide certification?
*
Yes
No
If Yes, what is your Home Care Aide Registration Number?
Home Care Aide Certificate
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of
Are you willing to undergo a background check, in accordance with local law and regulations?
*
Yes
No
Can you work overtime if necessary?
*
Yes
No
Can you reliably commute to this job's location?
*
Yes
No
Are you bi-lingual? If Yes, what language?
*
How would you rate you communication skills?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
By checking this box, you confirm that you have read and understood the caregiver application and information listed above.
*
Yes, I have read and understood the rules and etiquette of a Caring Heart emplooyee.
I have voluntarily provided the above contact information and authorize CARING HEART HOME CARE and it's representative to contact any of the above individuals on my behalf in the event of an emergency.
Signature
*
Submit CV
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