Employment Application
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have a cell phone with texting features?
*
Please Select
Yes
No
Email
*
example@example.com
Gender
*
Please Select
Female
Male
Other
Are you over 18 years of age?
*
Please Select
Yes
No
Are you authorized to work in the U.S.?
Please Select
Yes
No
Have you ever been convicted of a crime?
*
Yes
No
If YES , Please explain:
Please select the days and shifts you are available:
*
Rows
Day
Shift
7am-3pm
Evening
Shift3pm-11pm
Night
Shift
11pm-7am
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Are you available to work 12hr shifts ?
*
Please Select
Yes
No
Are you available to work overtime if required?
Please Select
Yes
No
Are you willing to provide service to a client with pets ( cat, dog ) ?
Yes
No
Are you willing to provide service to a client that smokes?
Please Select
Yes
No
How many miles from your home address are you willing to commute?
What is your desired hourly pay rate?
*
Preferred cities you would like to work in- Check all that apply
*
Fairfield
Vacaville
Vallejo
Benicia
Suisun City
Dixon
Green Valley
Napa
Calistoga
St.Helena
Yountville
American Canyon
Alameda
Oakland
Hayward
Fremont
Pleasanton
Berkeley
San Leandro
Livermore
Castro Valley
Dublin
Union City
Newark
Emeryville
Albany
San Lorenzo
Piedmont
Martinez
Concord
Walnut Creek
Antioch
Richmond
Brentwood
Pleasant Hill
Pittsburg
San Ramon
Danville
San Pablo
Oakley
Lafayette
Orinda
Pinole
El Cerrito
El Sobrante
Hercules
Moraga
Alamo
Clayton
Discovery Bay
Rodeo
Diablo
Pacheco
Do you have a reliable car?
*
Please Select
Yes
No
Do you have a valid drivers license?
*
Please Select
Yes
No
Are you registered with the CA DSS HCA ( HOME CARE AIDE ) registry?
*
Please Select
Yes
No
Do you have auto Insurance?
*
Please Select
Yes
No
Do you have a current TB test Result?
*
Please Select
Yes
No
Do you have a current CPR/FIRST AIDE certification?
*
Please Select
Yes
No
Have you been vaccinated against COVID-19?
*
Yes, fully vaccinated
No
Partially yes (only one dose)
Other
Certifications
Certificate Name
Expiry Date
-
Month
-
Day
Year
Date
Certificate Name
Expiry Date
-
Month
-
Day
Year
Date
Certificate Name
Expiry Date
-
Month
-
Day
Year
Date
Skills
Hospital
Hoyer Lift
Incontinent Care
Nursing Home
Slide Board
Oral Care
Private Home
Gate Belt
Mobility assist
Parkinson's
Meal preparation
Excercise
Dementia/ALZ
Bed Bath/Bathing
Med Reminders
Hospice Care
Dressing
Pet Care
Transportation
Education
Name
City, State
Major / Subject #
Years Attended
Graduate
High School
Yes
No
College/University
Yes
No
Vocational/Technical
Yes
No
Employment History
Current employer 1
Name of Employer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job title
Supervisor
From
-
Month
-
Day
Year
Date
to
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Previous employer 2
Name of Employer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Job title
Supervisor
From
-
Month
-
Day
Year
Date
to
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
References
Reference 1
Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
Years know
Reference 2
Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
Years know
When are you available to start?
*
-
Month
-
Day
Year
Date
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