Caregiver Employment Application Form

Caregiver Employment Application Form
Personal Information
PLEASE COMPLETE ALL QUESTIONS, PAGES 1-4
Date

MonthDayYear
Date
First:
Last:
Present Address:
Street
City
State
Zip
How long at this address?
Social Security No.
Cell Phone:

Country CodeArea CodePhone Number
Please indicate the days and times you are available to work
Please indicate the days and times you are available to work
Position applied for:
Salary range desired
How many hours can you work weekly?
Employment desired
When are you available to start work?
Where did you hear about us?
Email address
example@example.com
High School / GED
(City, State)
Years Completed
College
(City, State)
Have your ever been convicted of a crime?
If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation (A conviction will not necessarily result in the denial of employment)
Do you have any relatives or friends that work for the company?
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Emergency Contact

Do you have a valid driver's license or state Id?
Do you have active/current auto insurance?
Have you had any accidents during the past three years?
Reference Name 1
Company
Address
Address continued
Telephone where person can be reached 9a – 5p
Format: (000) 000-0000.
Reference Name 2
Company
Address
Address continued
Telephone where person can be reached 9a – 5p
Format: (000) 000-0000.
An application form sometimes makes it difficult to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications to be a caregiver. Please note any experience with caregiving professionally, for your parents, spouse, children or friends. Use additional sheets, if necessary.
Enter Response Here
Why do you enjoy caregiving?
Describe some of your volunteer work
Certification
APPLICATION FOR EMPLOYMENT (Continued)
Work Experience
Please list at least two of your work experiences for the past five years beginning with your most recent job held. If you were self-employed, give company name. Attach additional sheets if necessary.
Name and address of employer
Name of last supervisor
From
To
Phone number of supervisor
Format: (000) 000-0000.
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:
Name and address of employer
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:
PLEASE READ CAREFULLY
Page 4 of 4
Applicant's Statement & Acknowledgement. This application is not complete until it is fully completed, signed, and all statements below have been read and initialed.

Initial Below
I certify that all of the information furnished on this application and during the application process is true, complete and correct to the best of my knowledge. I understand that any misrepresentation or omission of facts called for may result in refusal to hire or, if hired,may result in my dismissal at any time regardless of when the false answer or omissions are discovered.
Initial
I recognize that this employment application is not an offer of employment. I agree that if I am hired by the Caring Shepherds Healthcare Inc, I will be an at-will employee, meaning that either the Company or I may end the employment relationship at any time with or without cause or notice. I understand that only administrator, Monica Adewale of Caring Shepherds Healthcare Inc, and no manager, supervisor, or other representative of the Company, has authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the at-will employment relationship, and with respect to any agreement entered into by the administrator, any such agreements must be in writing and signed by the administrator and by me or my authorized representative.
Initial
I further understand and agree that, if hired, my wages, hours, working conditions, job assignment(s), and compensation rate(s) will be subject to change by Caring Shepherds Healthcare Inc.
Initial
I understand that Caring Shepherds Healthcare Inc may share the information contained in this application with other Company employees for employment and administrative purposes and hereby consent to such transfer.
Initial
I hereby authorize, to the extent allowed by applicable federal state and local laws, Caring Shepherds Healthcare Inc, to conduct its own investigation of my references, employment history and education and, further, authorize the references and prior employers I have listed to disclose to the Company information related to my employment history and qualifications for the position for which I am applying, without giving me prior notice of such disclosure.
Initial
I agree and understand that, as an applicant to Caring Shepherds Healthcare Inc, I am subject to a live scan background check in accordance with the requirements of the Illinois Department of Public Health, and that employment for the position of Home Care Aide is contingent upon the results of the Live Scan background check.
Initial
Printed Name
Signature of applicant
Date

MonthDayYear
Date
Should be Empty:

Caregiver Employment Application Form

Personal Information

PLEASE COMPLETE ALL QUESTIONS, PAGES 1-4

Present Address:

APPLICATION FOR EMPLOYMENT (Continued)

Work Experience

PLEASE READ CAREFULLY

Page 4 of 4

Applicant's Statement & Acknowledgement. This application is not complete until it is fully completed, signed, and all statements below have been read and initialed.