1.1) Homemaker Job Application

Homemaker Job Application
As a Homemaker Services Worker (HSW) or Homemaker, you’ll provide non-medical, in-home assistance to seniors and individuals with disabilities—helping with light housekeeping, meal prep, errands, and daily activities to make their lives easier.
Applicant Demographic Information
Name

First NameMiddle NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Gender
Race/Ethnicity
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a means of transportation to clients' homes?
If a current employee referred you, please state his or her name below

Previous Relevant Employment
Previous Company Name (If no history, say N/A)
Previous Job Title
Responsibilities
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Supervisor Name
Supervisor Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

DISCLAIMER AND SIGNATURE

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any false or misleading information provided during the application or interview process may result in my disqualification or dismissal if employed. I also authorize the agency to conduct a background check and to contact my previous employers for verification of employment history.
Full Name

First NameMiddle NameLast Name
Signature
Should be Empty:

Homemaker Job Application