Loving Spirits Home Care
Employment Application - Home Health Care Staff
Full Name:
Date of Birth:
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Month
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Day
Year
Date
Phone Number:
Format: (000) 000-0000.
Email:
example@example.com
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Position Applied For:
Caregiver / HHA (Home Health Aide)
CNA (Certified Nursing Assistant)
Companion / Sitter
Other
Desired Employment:
Full-Time
Part-Time
PRN (As Needed)
Other
Available Start Date:
/
Month
/
Day
Year
Date
Desired Employment:
High School
Diploma/GED
College/Training
Degree/Certificate
School Name:
College Training:
Degree Certificate:
Certifications:
CNA
HHA
CPR/First Aid
TB Test / Chest X-Ray Clearance
Dementia/Alzheimer’s Care Training
Infection Control Training
Medication Administration Training
Other
Skills & Qualifications:
Personal Care (bathing, grooming, dressing)
Meal Preparation
Light Housekeeping
Medication Reminders
Companionship
Transportation / Errands
Mobility / Transfer Assistance
Dementia/Alzheimer’s Support
Other
Work Experience
Employer #1:
Position:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Dates:
/
Month
/
Day
Year
Date
Reason for Leaving:
Employer #2:
Position:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Dates:
/
Month
/
Day
Year
Date
Reason for Leaving:
May We Contact Your Previous Employer:
Yes
No
Background Information
Have you ever been convicted of a crime:
Yes
No
If yes explain:
Are you legally eligible to work in the U.S.:
Yes
No
Do you have reliable transportation:
Yes
No
References (Professional Only)
Name:
Phone:
Format: (000) 000-0000.
Relationship:
Name:
Phone:
Format: (000) 000-0000.
Relationship:
Background Check Authorization
I understand that as part of the employment process with Loving Spirits Home Care LLC, I may be required to undergo a criminal background check, reference verification, and/or other screenings as permitted by law. I authorize the release of this information to Loving Spirits Home Care LLC for employment purposes only.I acknowledge that any offer of employment may be conditional upon the successful completion of these checks. I further understand that any false, misleading, or incomplete information provided in my application may result in denial of employment or termination if discovered after hire.
Background Check Authorization:
Yes, I agree and authorize the background check
No, I do not authorize the background check
Liability Release Statement
I understand and agree that Loving Spirits Home Care LLC, its owners, staff, and affiliates are not liable for any personal injury, property loss, or damages that may occur outside the scope of my official job duties or as a result of my own actions, negligence, or misconduct. I further agree not to hold the company responsible for circumstances beyond its control.
Liability Release:
Yes, I agree and release Loving Spirits Home Care LLC from liability
No, I do not agree
Applicant Statement
I certify that the information provided is true and complete. I understand that false or misleading information may result in disqualification or termination if hired.
Signature
Date
/
Month
/
Day
Year
Date
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