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?
*
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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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
Upload a File
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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
Signature
*
By checking this box, you are confirming that you have read and understood the caregiver etiquette as listed above.
*
Yes, I have read and understood the rules and etiquette of a Caring Heart emplooyee.
Submit CV
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