Caregiver Application
Name
*
First Name
Middle Name
Last Name
Phone Number
*
E-mail
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security #
*
**for background check**
Total number of years experience in caregiving:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please select checkboxes that match your skills and preferences.
Alzheimer's/Dementia Experience
OK with cats
Live-In Shifts OK
OK with dogs
Ok with Client Smoking
Reliable & prompt
Able to commit to job timeline
18+ years old
Willing to drive clients
Safe & ensured vehicle
Can legally work in the U.S.
Ok with lifting client from bed/toilet
Available to work nights
Areas you are comfortable commuting to:
*
Distance Willing To Travel?
*
Please Select
Over 30 Mile Radius
Below 30 Mile Radius
Public Transit Only
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Employment Desired:
Date You Can Start
*
-
Month
-
Day
Year
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Position Interested In (check all that apply):
Full Time
Part Time
Temporary
On Call
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Additional Information:
What do you like most about working with the elderly, disabled, or convalescing?
*
List professional licenses you possess. Indicate type of license, number, and state: (type n/a if none)
*
Have you ever been charged with or convicted of any crime? If yes explain the nature of& dates or charge or conviction.
*
List any languages spoken:
*
How did you hear about Haven Home Care Agency?:
*
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Education:
Highest Level of Education:
*
Please Select
High School
College
Graduate School
High School
Name of High School Attended
Graduated High School?
Please Select
Yes
No
College
Name of College/University Attended
Graduated College?
Please Select
Yes
No
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Mandatory Job History
Current Employer Name
Current Employer Position
Your job title
Current Employer Start Date
-
Month
-
Day
Year
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Current Employer Location
i.e. Neighborhood
Current Employer Duties
Please include an in-depth job description
Current Employer May We Contact?
Yes
No
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 Start Date
-
Month
-
Day
Year
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Previous Employer End Date
-
Month
-
Day
Year
Date Picker Icon
Previous Employer Duties
Please include an in-depth job description
Previous Employer Reason for Leaving?
Previous Employer May We Contact?
Yes
No
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 Start Date
-
Month
-
Day
Year
Date Picker Icon
Third Recent Employer End Date
-
Month
-
Day
Year
Date Picker Icon
Third Recent Employer Employer Duties
Please include an in-depth job description
Third Recent Employer Reason for Leaving?
Third Recent Employer May We Contact?
Yes
No
Please explain why we may not contact your third recent employer:
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References:
Please include at least three
May we contact your references?
Yes
No
Reference One
Name of Reference
Reference One Relationship
Reference One Years Acquainted
Reference One Phone
Reference One Email
example@example.com
Reference Two
Name of Reference
Reference Two Relationship
Reference Two Years Acquainted
Reference Two Phone
Reference Two Email
example@example.com
Reference Three
Name of Reference
Reference Three Relationship
Reference Three Years Acquainted
Reference Three Phone
Reference Three Email
example@example.com
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Resume:
Please Upload Your Resume (optional)
Upload a File
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