EMPLOYMENT APPLICATION for HOME CARE WORKER

At Home By Choice Home Care LLC

EMPLOYMENT APPLICATION for HOME CARE WORKER
We’re excited to learn more about you! Please complete all sections of this form to help us move forward with your application. Providing accurate and complete information ensures that we can efficiently review your qualifications and proceed to the next steps of the process.

⚠️ Incomplete applications will not be considered.⚠️
Full Name*

First NameMiddle NameLast Name
Source
What Position you're applying for?
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cellphone Number
Please enter a valid phone number.
Email*
example@example.com
Date Of Birth*

MonthDayYear
Applicants must be 21 years of age or older to qualify for this position.
Social Security #*
GENDER*
What language do you speak?
Emergency Contact # Name & Phone Number of Person to contact in the event of an emergency:
Name *
Phone number (Local)*
Phone number (Out-of-Area)*
Relationship*
EDUCATION
Please use this section to provide information about your previous education including the qualifications/certificates your have gained.
Diploma
Year/Month Completed

MonthDayYear
Date
Certificate
Year/Month Completed

MonthDayYear
Date
Degree
Year/Month Completed

MonthDayYear
Date
Degree in what?
Certifications
⚠️ Work Limitations ⚠️

Please list any work limitations you may have and provide a brief description.
Hearing*
Speech*
Lifting*
Health*
Physical*
Emotional*
Other
Availability for Work
Please list below the hours and number of shifts per week that you are available to be scheduled. This form should be used to indicate ALL available hours and not just the IDEAL schedule. Please understand that weekly schedules are not guaranteed, nor is the total number of hours per week. Schedules are established based on the current service requirements of the client. Limited availability may result'in fewer hours and/or scheduled shifts per week.
Full-timePart-timeOn CallSplit Shift
Are you willing to be on a call rotation 7AM-10PM Monday - Saturday?*

	Start Time 7AM	End Time 10PM
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY

Are you willing to be on a call rotation 11PM to7AM or 7PM to 7AM Monday - Saturday for overnight shifts?*

OVERNIGHT*

	Start Time 7PM	End Time 7AM
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY

⏰ If the hours listed above do not work for you, please indicate your availability below. Include your available days (weekdays and weekends) and specific time ranges
What is the minimum number of hours you will work in one day?
What is the maximum number of hours you will work in one day?
How many hours per week are you looking to work?
Are you able to work in Lake and Porter county?*
📍 Location Requirement: Applicants must be available to work in both Lake and Porter Counties.
What is your current rate of pay at current employer?
"Do Not Leave any Lines Blank"

"Do Not Leave any Lines Blank"
Work History – 3 Required
⚠️ Important: Employment References Required

Providing employment references is an important part of the application process. Please include accurate and up-to-date contact information for professional references who can speak to your work experience and qualifications.

To ensure your application receives full consideration, make sure all fields in this section are completed. Incomplete information (such as missing work history, phone numbers, or supervisor names) may prevent us from moving forward with your application.

⚠️ Incomplete applications will not be considered.⚠️
Work Related #1(Last Position)
Company Name / NA is not Valid*

Street Address Line 2

CityState / Province

Postal / Zip Code
Address/ NA is not Valid*

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone No. & Email Address: / NA is not Valid*

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor’s Name / NA is not Valid*

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Held/ NA is not Valid*

Street Address Line 2

CityState / Province

Postal / Zip Code
Length of Employment / NA is not Valid*
Reason for leaving (Required) / NA is not Valid*
Work Related #2 (2nd Last Position)
Company Name / N/A is not Valid*

Street Address Line 2

CityState / Province

Postal / Zip Code
Address / N/A is not Valid*

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone No. & Email Address:/ N/A is not Valid*

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor’s Name / N/A is not Valid*

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Held / N/A is not Valid*

Street Address Line 2

CityState / Province

Postal / Zip Code
Length of Employment /N/A is not Valid*
Reason for leaving (Required) /N/A is not Valid*
Work Related #3 (3rd Last Position)
Company Name / N/A is not Valid*

Street Address Line 2

CityState / Province

Postal / Zip Code
Address/ N/A is not Valid*

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone No. & Email Address: / NA is not Valid*

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor’s Name / N/A is not Valid*

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Held/ N/A is not Valid*

Street Address Line 2

CityState / Province

Postal / Zip Code
Length of Employment / N/A is not Valid*
Reason for leaving (Required)/ N/A is not Valid *
Length of Employment / N/A is not Valid*
Reason for leaving (Required) / N/A is not Valid*
Personal References –2 Required
Please use this section to provide a list of three Personal references.
Personal #1
Name

Street Address

Street Address Line 2

CityState / Province
Address

Street Address

Street Address Line 2

CityState / Province
Telephone No. & Email Address

Street Address

Street Address Line 2

CityState / Province
Nature of Friendship (friend, co-worker) (Other than relative.)

Street Address

Street Address Line 2

CityState / Province
Personal #2
Name

Street Address

Street Address Line 2

CityState / Province
Address

Street Address

Street Address Line 2

CityState / Province
Telephone No. & Email Address

Street Address

Street Address Line 2

CityState / Province
Nature of Friendship (friend, co-worker) (Other than relative.)

Street Address

Street Address Line 2

CityState / Province
🏢FOR APPLICANTS APPLYING FOR OFFICE EMPLOYMENT🏢

This section is intended only for individuals applying for office-based positions.
What is your office experience?
Professional Phone Etiquette?
Proficiency in Microsoft Office?
How many words can you type per minute?
Are you a self-starter?
Can you multitask in a fast paced environment?Explain:
Have you had leadership training or been in a leadership role in the past?
Minimum requires that you are capable as at least of a caregiver lead
"Do Not Leave any Lines Blank"

I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained in this application, as required. Additionally, I authorize former employers, references and any other individual/organizations to provide information to At Home By Choice Home Care LLC and I hereby release and discharge any of the above and At Home By Choice Home Care LLC from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary.

I also understand that employment, for certain positions, may be conditional upon successful completion of drug testing and a criminal background check.

I further understand that, if hired, I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States.
We have a background check that we perform to everybody? Is there anything that may come up ? Have you ever been investigated for abuse, neglect or domestic violence?
Signature

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Date

MonthDayYear
Date
Emergency contact name and phone number outside your home
Name*
Phone Number*
Please enter a valid phone number.
Call Off’s must be called in, NO TEXTING. Please understand that we can avoid coverage gaps by keeping the office aware of your scheduled day off for an appointment. Initial Initial

When you call off or don’t show up, this causes a ripple effect within the company. If you do not show up for your scheduled shift, you will be leaving a client without care. This will be considered neglect and job abandonment.

If we do not know your whereabouts, we will be contacting your emergency contact. If we still have no knowledge of your whereabouts and if you are fine or not, we will call the non-emergency police number for them to do a wellness check.
"Do Not Leave any Lines Blank"
Should be Empty:

At Home By Choice Home Care LLC

EDUCATION

TRANSPORTATION

TRANSPORTATION TO CLIENT

ABUSE INVESTIGATION

Work History – 3 Required

Personal References –2 Required

🏢FOR APPLICANTS APPLYING FOR OFFICE EMPLOYMENT🏢