Clear Care Home Care Agency - Caregiver Employment Application

INSTRUCTIONS: Complete all questions on the application.

* Indicates a required field.

Date of Birth:*

MM/DD/YYYY

First Name:*

Last Name:*

Email Address*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How long at this address?:*

Are you at least 18 years of age or older?*

Enter Yes or No

Will you now or in the future require sponsorship for employment visa status?*

Enter Yes or No

Cell Phone Number:*

Position applying for:*

During the past 7 years, have you ever been discharged, suspended or asked to resign from any position?*

YesNoIf Yes, please explain:

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

Anytime

Salary range desired:*

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 United States?*

YesNo

When are you available to start work?*

Date

How did you hear about us?*

Social Security Number:*

XXX-XX-XXXX

Have you ever worked under a different name?*

YesNo

If YES, what was it and what was the reason?

Do you have any relatives or friends that work at Clear Care Home Care Agency?*

YesNo

If YES, what is their name(s)?

In Case of Emergency, Please Contact:

Name:*

Relation:*

Business Phone:*

Mobile Phone:*

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:*

Date

Have you had any accidents during the past three years?*

NoYes

If Yes, how Many?

Have you had any moving violations during the past three years?*

NoYes

If Yes, how Many?

List two professional references. DO NOT LIST relatives.

Reference 1*

Name

Type of Reference*

Company:*

Phone Number:*

Email Address:*

Reference 2*

Name

Type of Reference*

Company:*

Phone Number:*

Email Address:*

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.*

Why do you enjoy caregiving?*

Describe some of your volunteer work:*

Please check any certification(s) you currently possess:*

Additional Certifications/ Licenses

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.

1. Name and address of employer:*

Name of last supervisor:*

Employment dates:*

From

Employment dates:*

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 this 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:*

From

Employment dates:*

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 this employer?*

YesNo

If No, Please Explain Why and Please Provide Us With Another Work Reference:

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

In exchange for the consideration of my job application by Clear Care Home Care Agency LLC (hereinafter called “Clear Care Home Care Agency”), I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, or other Clear Care Home Care Agency company practices, shall serve to create an actual or implied contract of employment; nor to confer any right, to remain an employee of Clear Care Home Care Agency, or otherwise, to change in any respect, the employment-at-will relationship between it and the undersigned; and that relationship cannot be altered except by a written instrument signed by the Chief Executive Officer of Clear Care Home Care Agency. Clear Care Home Care Agency may end the employment relationship at any time, without specified notice nor reason. If employed, I understand that Clear Care Home Care Agency may unilaterally change or revise their benefits, policies and procedures, and such changes may include a reduction in benefits.

I also understand that (1) Clear Care Home Care Agency has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job related physical examinations.

I understand that, in connection with the routine processing of your employment application, Clear Care Home Care Agency may request from a consumer reporting agency, an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, Clear Care Home Care Agency will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I hereby release any and all prior employers or current employers from liability or claims arising out of the provision of information about my employment with such employer. I hereby waive any cause of action I might otherwise have against such employer arising out of the provision of information concerning my employment.

I further understand that my employment with Clear Care Home Care Agency shall be probationary for a period of sixty (60) days, and further, that at any time during the probationary period or thereafter, my employment relationship with Clear Care Home Care Agency is terminable at will for any reason from said party.

I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE. I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give Clear Care Home Care Agency permission to contact schools, previous employers (unless otherwise indicated), references, and others. I hereby release Clear Care Home Care Agency from any liability as a result of such contact.

Signature of applicant:*

Date:*

Date

Printed name:*

Clear Care Home Care Agency LLC 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, nor disability. We assure you that your opportunity for employment with Clear Care Home Care Agency depends solely on your qualifications.

Thank you for completing this application form and for your interest in

Clear Care Home Care Agency LLC.

Caregiver Employment Application

Personal Information

Education Information

Driving Information

Personal Reference Information

Work Experience

Skill Information

APPLICATION FORM WAIVER