Love Bug Care - Job Application

Name*

First NameLast Name
Job Application

Please complete the form below to apply for a position with us.
Street Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Information
Email Address*
example@example.com
Telephone*
Please enter a valid phone number.Format: (000) 000-0000.
Qualifications

Please select any of the following qualifications you may have.
Do you have reliable transportation?*

NoYes
Do you have a valid drivers license?*

NoYes
Have you ever been convicted of any law violation (except a minor traffic violation)?
Are you willing to undergo a background check? *

NoYes
Do you enjoy helping others?

NoYes
Are you vaccinated or have a valid medical or religious exemption from receiving a COVID-19 vaccine?

NoYes
Certifications

Please select any of the following certifications you may have.
CNA Certification

NoYes
HHA Certification

NoYes
PCA Certification

NoYes
Please list any additional certifications you may have in the space below.
Are you 21 years of age or older?*

YesNo
(If hired, you may be required to submit proof of age.)
Submit a copy of your drivers license
Social Security # - If hired, can you furnish proof you are eligible to work in the U.S.?*

YesNo
Submit a copy of your social card
List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references.
EMPLOYER 1
NAME OF EMPLOYER

Company Name
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
JOB TITLE AND DUTIES
SUPERVISOR
DATES OF EMPLOYMENT:
FROM

MonthDayYear
Date
TO

MonthDayYear
Date
PAY
START $
FINAL $
REASON FOR LEAVING
TELEPHONE
Please enter a valid phone number.Format: (000) 000-0000.
EMPLOYER 2
NAME OF EMPLOYER

Company Name
JOB TITLE AND DUTIES
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SUPERVISOR
DATES OF EMPLOYMENT:
FROM

MonthDayYear
Date
TO

MonthDayYear
Date
PAY
START $
FINAL $
TELEPHONE
Please enter a valid phone number.Format: (000) 000-0000.
REASON FOR LEAVING
Upload Your Resume

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We do not discriminate on the basis of age over 40, race, sex, color, religion, national origin, disability, or any other applicable status protected by state or local law. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors.
This information (Birth date and SSN) will be used for background screening purposes only and will not be taken into consideration in making any employment decisions.

Pirating practices or hiring a caregiver directly and secretly without the consent of Love Bug Care, LLC. is strictly prohibited.

By signing this agreement, the caregiver agrees to these terms.
Signature
What language do you speak?
What language do you speak? If multiple languages.
Shift Preference

1st Shift2nd Shift3rd ShiftPart TimeFull TimeOther
Date of Birth

MonthDayYear
Date You Can Start

MonthDayYear
Salary Desired
Should be Empty:

Job Application

Contact Information

Qualifications

Certifications

EMPLOYER 1

DATES OF EMPLOYMENT:

PAY

EMPLOYER 2

DATES OF EMPLOYMENT:

PAY