Staff Intake Form

Caregiver Employment Application
Applicant Full Name
Email
example@example.com
Phone Number
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
CNA/GNA License Number
License Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
CPR Certification Status
Upload CNA/GNA License (front/back)

Cancelof
Upload CPR Card (if available)

Cancelof
Upload ID or Work Eligibility Document

Cancelof
Upload Resume (PDF or WORD)

Cancelof
Experience & Skills (select all that apply)
If Other or Special Skills, describe here:
Which days are you available to work? (select all that apply)
Shift preference (select all that apply)
Available working hours (ex: 7a-3p)
How many miles are you willing to travel? (ex: 10 miles, 20 miles, no limit)
When are you able to start working

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How many years of experience do you have?
I understand the pay rate is $18/hr and hours are client specific and no guaranteed shifts.
Type full legal name to sign and certify information is true to the best of my knowledge.
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
“Applicants may be contacted by email first to confirm position alignment before any phone interview is scheduled.”
Employment is contingent upon a satisfactory background check.
Employment History
Employer Name
Job Title
Employment Dates
Main Duties
Supervisor Name
Supervisor Phone or Email
Reason for Leaving
Professional References
Reference 1 Name
Relationship
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Reference 2 Name
Relationship
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Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Transportation and Driving
Do you have reliable transportation?
Do you have a valid driver’s license?
Do you have current auto insurance if driving clients?
Applicant Agreements
I authorize contact with my references.
I consent to follow-up by phone, text, or email.
I confirm that the information provided is accurate.
I acknowledge the privacy notice.
I acknowledge that Williams Signature Care is an equal opportunity employer.
Application Information

Williams Signature Care provides non-medical home care in Waldorf, Charles County, and surrounding areas. Applications are reviewed for current openings. Qualified applicants may first be contacted by email. Submission does not guarantee employment.
Should be Empty:

Caregiver Employment Application

Employment History

Professional References

Transportation and Driving

Applicant Agreements

Application Information