1ST CHOICE PERSONAL CARE LLC job application updated

1ST CHOICE PERSONAL CARE LLC
WHERE MEMORIES ARE CHERISHED IN THE COMFORT OF YOUR HOME
EMPLOYMENT APPLICATION

Have you received Covid-19 Vaccine?YESNO
If yes, are you FULLY Vaccinated

YESNO
Name: (First)
Name: (Last)
Address
City
State
Zip Code
Phone
Email
example@example.com
DOB(MM/DD/YYYY)
SSN
Male/Female
Language
Diploma
Certification
Degree
Other Education
1. Emergency Contact Name
Emergency Contact Phone Number
1ST CHOICE PERSONAL CARE LLC
WHERE MEMORIES ARE CHERISHED IN THE COMFORT OF YOUR HOME
Emergency Contact Address
Relationship
CPR (YES/NO) If yes (expiration Date)

MonthDayYear
CPR CARD (If applicable)

Cancelof
Indicate years of experience of each below:
Bathing/showering
Housekeeping
Grooming/Dressing
Laundry
Toileting care
Meal Preparation
Shopping
Running Errands
Feeding
Medication Reminder
Transfers
Transfers with stand up lift
Hoyer Lift
Ambulation
Socialization
Other
Indicate days and Hours available for work:
Sunday
From
To
Monday

Monday:
From
1ST CHOICE PERSONAL CARE LLC
WHERE MEMORIES ARE CHERISHED IN THE COMFORT OF YOUR RHOME
To
Tuesday

Tuesday:
From
To
Wednesday

Wednesday:
From
To
Thursday

Thursday:
From
To
Friday

Friday:
From
To
Saturday

Saturday:
From
To
What are the minimum hours you will work in one day?
What are the maximum hours you will work in one day?
What Duties Do you prefer to work?
Companion Personal Care

Homemaker
Personal Care
Run Errands
Housekeeping
Clients Your Not able/willing to work with?
Dementia/Alzheimer's
Physical Disabilities
Smoker

Mental retardation
Smoker
Pets
Behavioral disorders

Females
Behavioral disorders
Females
HIV/Aides
Covid 19
1ST CHOICE PERSONAL CARE LLC
WHERE MEMORIES ARE CHERISHED IN THE COMFORT OF YOUR HOME
Work History

MonthDayYear
Date of Hire
Reason for leaving
Employer Name
Position Held
End of employment date

MonthDayYear
Date
Reason for Leaving
Previous Employer
Position Held
Date of Hire

MonthDayYear
Date
End of employment date

MonthDayYear
Date
Reason for Leaving
Work Reference
Company Name
Address
Telephone
Email
example@example.com
Fax Number
Supervisor Name
1ST CHOICE PERSONAL CARE LLC
WHERE MEMORIES ARE CHERISHED IN THE COMFORT OF YOUR HOME
Length of employment
Personal Reference
Address
Telephone
Email
example@example.com
Relationship
Years of Known
TRANSPORTATION
If No what is your mode of transportation?
Check One

BusCabUber
Check One

Friend
WHERE MEMORIES ARE CHERISHED IN THE COMFORT OFYOURHOME
PLEASE UPLOAD PHOTO ID

Cancelof
PLPEASE UPLOAD SOCIAL SECURITY CARD

Cancelof
Should be Empty:

1ST CHOICE PERSONAL CARE LLC

1ST CHOICE PERSONAL CARE LLC

1ST CHOICE PERSONAL CARE LLC

1ST CHOICE PERSONAL CARE LLC

1ST CHOICE PERSONAL CARE LLC

TRANSPORTATION