Form 1.2 BetterDays App 2.3

APPLICATION FORM
* Filing up this form puts you on our database that we call when an opportunity to serve our clients opens up.
* This does not guarantee employment.
* You understand that part of the application is background and reference checking.
* If you want to proceed, please click NEXT.

WELCOME

Thank you for your interest in joining our team.
Pls. have these documents ready next to you. To complete this form, you need to upload them at the end of this application. If not you cannot save your data. Pls. have them ready.

DATE
Date*

MonthDayYear
Date
Date

MonthDayYear
Date

PERSONAL INFO.
LAST NAME*
FIRST NAME*
MIDDLE
Yrs of experience*
MOBILE#*
EMAIL*
example@example.com

ADDRESS
ADDRESS*
We will send tax documents to this address.
UNIT/ APT#
CITY*
STATE*
ZIP*

IDENTIFIERS/ GENDER/ PRONOUN
SOCIAL SECURITY NUMBER/ ITIN*
RETYPE YOUR LAST NAME*
DATE OF BIRTH*

MonthDayYear
Date
BIRTH COUNTRY*
HEIGHT*
WEIGHT*
LBS
GENDER*
Gender for Insurance Purposes
Preferred GENDER*
Preferred
PRONOUN*
Optional

ID/ CA DL/ DMV
IDENTIFICATION (CA ID/ DL/ DMV/ OTHER ID)
DOCUMENT TYPE*
CA DL/ ID#/ PPORT#*
EXPIRY DATE*

MonthDayYear
HAIR COLOR*
EYE COLOR*
CAN DRIVE?*
HAS AUTOMOBILE?*
ANY RECENT VIOLATION?*

CATEGORIES
W4 : FEDERAL/STATE TAX
Tax Preferred Status*
Tax Allowance*
W9 : TAX PAYER ID
Tax Classification*
For LLC only
I-9 : EMPLOYMENT ELIGIBILITY
Legal Status*
ID#/ A#
OTHER INFO.

HOME CARE AIDE (HCA)

California requires all care providers to be registered.
HOME CARE AIDE# (State of California HCA (California Department of Social Services: CDSS)
HCA# (If none, we will guide you to get one.)
HCA ISSUED DATE#

MonthDayYear
Date
HAVE YOU EVER BEEN CONVICTED OF A CRIME IN CALIFORNIA?
Convicted of a crime in California?*
IF YOU ANSWERED YES, AND WAS CONVICTED OF A CRIME IN CALIFORNIA, PLS EXPLAIN
Convicted of a crime outside California?*
IF YOU ANSWERED YES, AND WAS CONVICTED OF A CRIME FROM ANOTHER STATE, FEDERAL COURT, MILITARY OR JURISDICTION OUTSIDE OF THE U.S.?, PLS EXPLAIN

CONTACTS
IN CASE OF EMERGENCY, WE CAN CONTACT*
MOBILE#*
Relation*
OTHER CONTACT
MOBILE#
Relation

REFERENCES
LIST OF TWO REFERENCES WHO CAN GIVE INFORMATION ABOUT YOUR BACKGROUND, CHARACTER AND ABILITIES.
REFERENCE 1 *
MOBILE*
Relation*
REFERENCE 2*
MOBILE#*
Relation*

MOST RECENT EMPLOYER
Name of employer
Telephone
Job title/ position
Reason for leaving
From
To

PROFESSIONAL/ TECHNICAL QUALIFICATIONS
A. List Licenses or Certificates of Competence held
B. Name of Professional Associations of which you are a member

EDUCATIONAL BACKGROUND
SCHOOL 1
COURSE TITLE/ DEGREE
SCHOOL NAME/ CITY/ COUNTRY
YEAR ATTENDED
SCHOOL 2
COURSE TITLE/ DEGREE
SCHOOL NAME/ CITY/ COUNTRY
YEAR ATTENDED

TERMS AND CONDITIONS
I agree to fully participate in completing the hiring process by going through a background check.*
I verify that all information I stated to this form are true and correct.*
I verify that all information I stated to this form are true and correct.*
I agree not to solicit and offer my services directly to Clients of Better Days Provider including Clients family and friends.*
I agree not to tell personal problems to my clients.*
I agree to do my best to help, protect and respect my Clients and coworkers.*
Client abandonment is considered an Elder Abuse, I agree not to abandon a Client.*
I agree not to borrow money from Clients and/ or their family.*
I agree not to engage Clients and their family to any businesses without prior approval from Better Days Provider Management.*

OTHER INFO.
Any information you'd like to share with us?

UPLOAD

PLS. HAVE YOUR ID/ VACCINE RECORD AND PHOTO READY.

CA DL/ ID/ GOVERNMENT ISSUED ID
FRONT: Upload a copy or take a photo of your ID.*

Cancelof
BACK: Upload a copy or take a photo of your ID.*

Cancelof

COVID19 VACCINE RECORD

(Optional)
Page 1: Upload a copy of your COVID19 Vaccine Record

Cancelof
Page 2: Upload a copy of your COVID19 Vaccine Record

Cancelof
Page 3 (if any): Upload a copy of your COVID19 Vaccine Record

Cancelof
Page 4 (if any): Upload a copy of your COVID19 Vaccine Record

Cancelof

PHOTO

Your most recent/ clear photo we can use for your file
Upload a most recent photo of yours. (No hats/ no dark glasses/clear background)*

Cancelof

SIGNATURE
FULL NAME
Signature

Powered by Jotform SignClear
Better Days Provider Inc. Copyrights (C) 2008-2023

SUBMIT

Pls. review and submit your application.
Please make sure you review all information you provided.

To submit this application, please type your FIRST NAMEblank* and click submit.
Should be Empty:

APPLICATION FORM

* Filing up this form puts you on our database that we call when an opportunity to serve our clients opens up.

* This does not guarantee employment.

* You understand that part of the application is background and reference checking.

* If you want to proceed, please click NEXT.

WELCOME

DATE

PERSONAL INFO.

ADDRESS

IDENTIFIERS/ GENDER/ PRONOUN

ID/ CA DL/ DMV

IDENTIFICATION (CA ID/ DL/ DMV/ OTHER ID)

CATEGORIES

W4 : FEDERAL/STATE TAX

W9 : TAX PAYER ID

I-9 : EMPLOYMENT ELIGIBILITY

HOME CARE AIDE (HCA)

HAVE YOU EVER BEEN CONVICTED OF A CRIME IN CALIFORNIA?

CONTACTS

REFERENCES

MOST RECENT EMPLOYER

PROFESSIONAL/ TECHNICAL QUALIFICATIONS

EDUCATIONAL BACKGROUND

SCHOOL 1

SCHOOL 2

TERMS AND CONDITIONS

OTHER INFO.

UPLOAD

CA DL/ ID/ GOVERNMENT ISSUED ID

COVID19 VACCINE RECORD

PHOTO

SIGNATURE

SUBMIT