Caregiver Job Application

Caregiver Application
Name

First NameMiddle NameLast Name
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
If applying for a specific position, list the job title here:
Total number of years experience in caregiving:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I meet the following requirements (check all that apply):
Are you 21 years of age or older?
Are you authorized to work In The United States?
Where are you located?
Please list the neighborhood you reside in.
Do You Own A Car?
Do You Have A Drivers License?
Areas you are comfortable commuting to: Examples (Jackson, Thomasville, Grovehill, Chatom, Tibbie, Leroy, and Saint Stephens
Distance Willing To Travel?
Employment Desired:
Date You Can Start

MonthDayYear
Salary Desired
Position Interested In (check all that apply):
Experienced With:

Other
Skills/Qualifications:
CPR/First Aid Certified?
CPR/First Aid Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
OPTIONAL: Upload a recent photo of yourself (5MB or smaller gif, png, jpg, or jpeg file)

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Education:
Highest Level of Education:
High School
Name of High School Attended
Graduated High School?
College
Name of College/University Attended
Graduated College?
Number of Years Attended College
Graduate School
Name of Graduate School Attended
Graduated Grad School?
Number of Years Attended
Area of Study/Degree
Trade School/Other
Name of Trade/Technical/Other School Attended
Graduated From Trade School?
Number of Years Attended
List of other professional training:
i.e. STARS, NCS, Doula training, conference workshops, etc.
Job History
Current Employer Name
i.e. Name of Family
Current Employer Position
Your job title
Current Employer Salary
Current Employer Start Date

MonthDayYear
Current Employer Location
i.e. Neighborhood
Current Employer Duties
Please include an in-depth job description
Current Employer May We Contact?
Please explain why we may not contact your current employer:
Previous Employment
Previous Employer
i.e. Name of Family
Previous Employer Position
Your job title
Previous Employer Salary
Previous Employer Start Date

MonthDayYear
Previous Employer End Date

MonthDayYear
Previous Employer Location
i.e. Neighborhood
Previous Employer Duties
Please include an in-depth job description
Previous Employer Reason for Leaving?
Previous Employer May We Contact?
Please explain why we may not contact your previous employer:
Third Recent Employer
i.e. Name of Family
Third Recent Employer Position
Your job title
Third Recent Employer Salary
Third Recent Employer Start Date

MonthDayYear
Third Recent Employer End Date

MonthDayYear
Third Recent Employer Location
i.e. Neighborhood
Third Recent Employer Employer Duties
Please include an in-depth job description
Third Recent Employer Reason for Leaving?
Third Recent Employer May We Contact?
Please explain why we may not contact your third recent employer:
References:

Please include at least three
May we contact your references?
Reference #1
Name of Reference
Reference #1 Relationship
Reference #1 Years Known
Reference #1 Phone
Reference #2
Name of Reference
Reference #2 Relationship
Reference #2 Years Known
Reference #2 Phone
Cover Letter & Resume:
Please Upload Your Cover Letter

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Acknowledgement
Should be Empty:

Caregiver Application

Employment Desired:

Skills/Qualifications:

Education:

Job History

References:

Cover Letter & Resume: