Personal Care Assistant Job Application
Please complete the form below to apply for a position with us.
Full Name
*
First Name
Last Name
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Do you have any experience working with people with disabilities? If yes, please explain.
*
Would you be willing to attend required training and pass a competency exam with a score of 80% or better?
*
Yes
No
Are you willing to work with:
*
Males
Females
Older persons
What age range do you prefer to work with?
*
Please indicate those areas in which you are willing to assist:
Meals
Meal Preparation
Dressing
Showering / Bathing
Feeding
Toilet Routine
Bowel and Bladder Care
Transfers to and from bed, wheelchair, vehicle, chair
Errands
Housekeeping
Laundry
Cleaning
Grocery Shopping
Shopping
Transportation / Escorting
Socializing
Recreation
Please indicate those areas in which you are willing to assist:
*
Rows
Select all that apply
Meals
Dressing
Feeding
Bowel and Bladder Care
Errands
Laundry
Grocery Shopping
Transportation / Escorting
Recreation
Meal Preparation
Showering / Bathing
Toilet Routine
Transfers to and from bed , vehicle, chair
Housekeeping
Cleaning
Shopping
Socializing
Is there any population of persons with disabilities that you would feel uncomfortable with?
*
Rows
Select any that apply, or select "none".
If you select "other," please specify below
Physical
Mental Illness
HIV
Cognitive
Sensory
Other
None
If you selected "other", please specify:
Do you have a driver's license?
*
Yes
No
Do you own a car?
*
Yes
No
What shifts would you prefer?
*
Days
Afternoons
Nights
Weekends
How did you hear about us?
*
References
Please provide names and contact information for three (3) references. At least one reference listed should be someone who worked with you as your supervisor. We will contact references by text message. Please make sure they are prepared to respond.
Reference 1: Name
*
First Name
Last Name
Affiliation to Reference 1
*
Please tell us your affiliation with this reference.
Reference 1: Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 1: Email
*
example@example.com
Reference 2: Name
*
First Name
Last Name
Affiliation to Reference 2
*
Please tell us your affiliation with this reference.
Reference 2: Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 2: Email
*
example@example.com
Reference 3: Name
*
First Name
Last Name
Affiliation to Reference 3
*
Please tell us your affiliation with this reference.
Reference 2: Email
*
example@example.com
Reference 3: Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Previous Work Experience
Would you like to upload your resume or enter your previous work experience in this form?
*
Upload my resume
Enter my previous work experience in this form
Upload your resume
*
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Company 1
*
Company 1 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Business
*
Job Title
*
Dates of Employment
*
Please include start and end date
Reason for Leaving
*
Company 2
*
Company 2 Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Business
*
Job Title
*
Dates of Employment
*
Please include start and end date
Reason for Leaving
*
Company 3
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Business
*
Job Title
*
Dates of Employment
*
Please include start and end date
Reason for Leaving
*
Company 4
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Business
*
Job Title
*
Dates of Employment
*
include start and end date
Reason For Leaving
*
Certification
I certify that the facts contained in this application are true and complete to the best of my knowledge and I understand if employed, falsified statements on the application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any all information concerning my previous employment. *
Date of application
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Enter the date you are submitting this application
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