Employment Application for Homecare Workers

Employment Application

Join our dedicated team at Devoted Caregivers and make a meaningful impact in the lives of our clients. We are looking for compassionate and skilled caregivers committed to providing exceptional home care. Apply now to become a part of our mission to enhance the quality of life for those we serve.
Name*

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email Address*

Confirmation Emailexample@example.com
Date of Birth

MonthDayYear
Date
Social Insurance Number
Gender
Emergency Contact 1
Emergency Contact 2
Formal Education
Do you have current First Aid Certification (State Level):
Please Include Expiry Date
Do you have current CPR?
Please Include Expiry Date
Other Certifications:
Please Include Expiry Date
List any work limitations that you may have and briefly describe:
Please explain:
Work Availability

Indicate Days and List Hours Available for Work:
Work Availablity
Indicate Days and List Hours Available for Work:
Monday 9am to 5pm
Tuesday 9am to 5pm
Wednesday 9am to 5pm
Thursday 9am to 5pm
Friday 9am to 5pm
Saturday 9am to 5pm
Sunday 9am to 5pm
What is the minimum number of hours you will work in one day?
Experience
Indicate which of the following you have experience in:
Are you restricted in the geographical location you are willing/able to work?
Yes or No. If Yes, Please explain:
Transportation
Type of transportation
Do you have a valid driver's license?
Are you willing to transport clients in your private vehicle?
Do you have adequate vehicle insurance?
Are you willing to drive a client’s vehicle?
Are you willing to escort a client in their own vehicle?
Have you ever been investigated for abuse, neglect or domestic violence?
If yes, please explain:
Reference Information

Work-Related #1 (Last Position):

	Please Input Information Below:
Company
Address
Phone
Email Address
Supervisor's Name
Position Held
Length of Employment
Reason for Leaving

Work Related #2 (2nd Last Position):

	Please Input Information Below:
Company
Address
Phone
Email Address
Supervisor's Name
Position Held
Length of Employment
Reason for Leaving

Work Related #3 (3rd Last Position):

	Please Input Information Below:
Company
Address
Phone
Email Address
Supervisor's Name
Position Held
Length of Employment
Reason for Leaving

Personal 1:

	Please Input Information Below:
Full Name
Address
Phone
Email Address
Nature of friendship

Personal 2:

	Please Input Information Below:
Full Name
Address
Phone
Email Address
Nature of friendship

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 Devoted
Caregivers and I hereby release and discharge any of the above and Devoted Caregivers 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
Date*

MonthDayYear
Date
Signature*

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Employment Application

Work Availability

Experience

Transportation

Reference Information