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EMPLOYMENT APPLICATION FORM
GENERAL INFORMATION
Full Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
What position are you applying for?
Are you 18 Years or Older?
*
Yes
No
Number
Are you authorize to work lawfully in the United States?
*
Yes
No
Have you ever been convicted of a felony or misdemeanour?
*
Yes
No
CONTACT INFORMATION
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
*
-
Country Code
-
Area Code
Phone Number
Mobile Phone Number
*
-
Country Code
-
Area Code
Phone Number
E-mail
*
TRANSPORTATION
Do you have a Driver's License?
*
Yes
No
Proof of Insurance?
*
Yes
No
AVAILABILITY
Date Available
*
-
Month
-
Day
Year
Date Picker Icon
Employment Desired
*
Full Time
Part Time
Expected Hourly Rate
*
Amount in $
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Holidays
Please indicate the Types of Services in which you are willing to provide
Companionship
Meal Preparation
Light Housekeeping
Games/Arts&Craft
Laundry / Ironing
Personal Care
Medication Reminder
Errands / Transportation
Dementia / Alzheimer's
Are you comfortable cooking from scratch?
*
Yes
No
Are you willing to give your service to a client that smokes?
*
Yes
No
Are you willing to give your service to a client with pet?
*
Yes
No
Social Security Number
INTERESTS & HOBBIES
Please indicate the activities you enjoy and / or able to teach to someone else
*
Arts & Crafts
Hairdressing
Sewing
Board/Card Games
Gardening
Puzzles
Makeup
Cooking/Baking
Conversationalist
Crocheting
Knitting
Reading to Client
Other
EDUCATION
*
SCHOOL (Name & Address)
GRADUATION
YEAR
NUMBER OF YEARS COMPLETED
DIPLOMA DEGREE
HIGHSCHOOL
COLLEGE / UNDERGRADUATE
GRADUATE / PROFESSIONAL
CERTIFICATE & LICENSES
SPECIALIZED EXPERIENCE, VOLUNTEER WORK, TRAINING, SKILLS
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WORK HISTORY
EMPLOYER I
Position
Job Description
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Month & Year
Salary
Phone Number
-
Area Code
Phone Number
Please Select
Option 1
Option 2
Option 3
Reason for Leaving
_______________________________________________________________________________________
EMPLOYER II
Position
Job Description
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Month & Year
Salary
Phone Number
-
Area Code
Phone Number
Reason for Leaving
_______________________________________________________________________________________
EMPLOYER III
Position
Job Description
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Month & Year
Salary
Phone Number
-
Area Code
Phone Number
Reason for Leaving
PERSONAL REFERENCES
Name
*
Relationship
*
Contact Number
*
Name
Relationship
Contact Number
Name
Relationship
Contact Number
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