AOG Hom Care Services

Caregiver Employment Application
Personal Information
Date:

MonthDayYear
Date
Last:*
First:*
Middle:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone:*
Position applied for:
Have you ever applied here before?

YesNo
Please indicate the days and times you are available to work:

Anytime
How many hours can you work weekly?*
Are you available to work nights?

YesSomeNone
Are you available to work weekend nights?

YesSomeNone
Employment desired?

Part-Time OnlyFull or Part-TimeFull Time Only
Are you legally authorized to work in the US?*

YesNo
When are you available to start work?*

MonthDayYear
Date
Email address:*
example@example.com
Social Security:
Education Information
Driving Information
Do you have a valid drivers license?*

YesNo
Do you have auto insurance?*

YesNo
Do you have a car?

YesNo
If no, how would you get to work?
Driver's License No.:
State of Issue:
Expiration Date:

MonthDayYear
Date
Personal Reference Information
List two personal references. DO NOT LIST relatives or previous supervisors.
Reference 1
Name
Type of Reference

FriendCo-workerTeacherPastorFriendCurrent ClientFormer Client
Company:
Address:
Telephone where person can be reached 9a - 5p
Reference 2
Name
Type of Reference

FriendCo-workerTeacherPastorFriendCurrent ClientFormer Client
Company:
Address:
Telephone where person can be reached 9a - 5p
Please check any certification(s) you currently possess:

Certified Nursing AssistaneCertified Medication AideGeriatric Nursing AssistanceMedication TechnicianCPR CertificationFirst Aide Certification
Work Experience
1. Name and address of employer:
Name of last supervisor:
Please list at least two of your work experiences in the past five years beginning with your most recent job held. If you were self employed, give company name. Attach additional sheets if necessary.
Employment dates:

MonthDayYear
From
Employment dates:

MonthDayYear
To
Phone number:
Your Last Job Title:
Reason for leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:
May we contact your present employer?

YesNo
If No, Please Explain Why and Please Provide Us With Another Work Reference:
2. Name and address of employer:
Name of last supervisor:
Employment dates:

MonthDayYear
From
Employment dates:

MonthDayYear
To
Phone number:
Your Last Job Title:
Reason for leaving (be specific):
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:
May we contact your present employer?

YesNo
If No, Please Explain Why and Please Provide Us With Another Work Reference:
Skill Information
How would you rate yourself on your experience with the following aspects of caregiving? 1 = No Experience 2 = Some Experience 3 = Good Experience 4 = Excellent Experience
Companionship

1234
Meal Preparation

1234
Light Housekeeping

1234
Bathing/Showering

1234
Dressing/Grooming

1234
Transferring

1234
Incontinence Care

1234
Dementia/Alzheimer's Care

1234
Comments
Date:

MonthDayYear
Date
Printed name:
AOG Home Care Services is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.

Please return this application to our office at your earliest convenience.

1 Chick Springs Rd Suite 214-A Greenville SC 29609

Phone 864-236-1758
Should be Empty:

Caregiver Employment Application

Personal Information

Education Information

Driving Information

Personal Reference Information

Work Experience

Skill Information