Around The Clock Home Care 

Address: 2424 Franklin st Michigan City IN 46360

Phone: (219)-561-3465

Fax: (219)-245-6434

It is the policy of Around The Clock Home Care to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability, or veteran status.

Applicant Full Name   First Name   Last Name   

Home Address:   Street Address   Address Line 2   City   State   Zip   

Number of Years at this address?      

Mobile Phone Number:   Area Code   Phone Number   

Social Security Number:      

Drivers License/ State ID Number:     

Who should be contacted if you are involved in an emergency? 

Contact Name:    First Name   Last Name   
Relationship to you:      
Address:   Street Address   Address Line 2   City   State   Zip   

Mobile Number:   Area Code   Phone Number   

Position Applying For    Please Select Caregiver Human Resources    
Full Time/ Part Time:    Please Select Full Time Part Time    

How did you hear about Around The Clock Home Care?      
Do you have friends or relatives that work for our company?    Please Select Yes No     If so, please list their first and last name here.   First Name   Last Name   

Have you previously applied for a position with Around The Clock Home Care?     Please Select Yes No         

Are you at least 18 years or older?    Please Select Yes No    
How will you get to and from work?    Please Select Personal Vehicle Shared Vehicle Public transportation I utilize family and friends    
What is your availability?    Please Select Open Availability Mon-Fri Weekends Only PRN Overnights       


If you are offered the position, when will you be able to begin working?      

If hired, are you able to submit proof that you are legally eligible for employment in the United States?    Please Select Yes No    

Are you able to perform the essential functions of the job position you seek with or without reasonable accommodation?    Please Select Yes No  

What Reasonable accommodations, if any, would you request?   Type a label 

 Do you have experience working in this field?    Please Select Type Option 1 Type Option 2 Type Option 3    If so, what would you say your skill levels are? Please list below. With 1 being inexperienced and 5 being very experienced.

Personal Care    Please Select 1 2 3 4 5    
Bathing    Please Select 1 2 3 4 5    
Feeding    Please Select 1 2 3 4 5    
Errands    Please Select 1 2 3 4 5    
Light Housekeeping    Please Select 1 2 3 4 5    
Meal Prep    Please Select 1 2 3 4 5    
Transportation    Please Select 1 2 3 4 5    

EMPLOYMENT HISTORY

List your current or most recent employment first. Please list all jobs (including self-employment and military service) which you have held, beginning with the most recent, and list and explain any gaps in employment. If this will be your first job please write N/A in each space to move forward.

1.
Company Name:    First Name  
Dates of Employment:      
Supervisor Name:   First Name   Last Name   
Address:   Street Address   Address Line 2   City   State   Zip   
Company Contact Phone Number:   Area Code   Phone Number   
Job Duties:      
Reason for leaving:      
May we contact this employer?    Please Select Yes No    

2.
Company Name:    First Name      
Dates of Employment:      
Supervisor Name:   First Name   Last Name   
Address:   Street Address   Address Line 2   City   State   Zip   
Phone Number:   Area Code   Phone Number   
Job Duties:      
Reason for leaving:      
May we contact this employer?    Please Select Yes No    

         High School

High School Name      Street Address   Address Line 2   City   State   Zip   Area Code   Phone Number   Year Graduated   

College

Name Of College         Street Address   Address Line 2   City   State   Zip      Area Code   Phone Number Year Graduated     

Please indicate any current professional licenses or certifications that you hold:
Awards, Honors, Special Achievements:   Type a label   

Other Training (graduate, technical, vocational).   Type a label   

Personal References

List any three non-relatives who would be willing to provide a reference for you.

1.First Name   Last Name   
Area Code   Phone Number   Email   
Type a label   

2.   First Name   Last Name   
Area Code   Phone Number   Email   
Relationship to you   

3.   First Name   Last Name   
Area Code   Phone Number   Email   
Type a label   

18. Please provide any other information that you believe should be considered, including whether you are bound by any agreement with any current employer.   Type a label