• Name*
  First NameMiddle NameLast Name
• Today’s Date
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• Position(s) Applied For*
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• Phone Number*
  Format: (000) 000-0000.
• Email
  example@example.com
• Address*
  Street Address

  Street Address Line 2

  CityState / Province

  Postal / Zip Code
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• Emergency Contact

• Emergency Contact Name
  First NameLast Name
• Emergency Contact Phone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
• Relationship*
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• Employment History (General)

• Have you applied with us before?*
  YesNo
• If yes, when?
• Have you worked with us before?*
  yesNo
• If yes, when?
• How did you hear about us?*
• Have you reviewed the job description?*
  YesNo
• Are you legally able to work in the U.S.?*
  YesNo
• Are you at least 18 years old?*
  YesNo
• Are you able to perform job duties with or without accommodation?*
  YesNo
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• Availability

• Available Start Date*
   -Month -DayYear

  Date
• Availability*
  MorningsAfternoonsEveningsOvernightsWeekdaysWeekends
• Weekly Availability (Per Day)*
  Monday: From – ToTuesday: From – ToWednesday: From – ToThursday: From – ToFriday: From – ToSaturday: From – ToSunday: From – To
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• Work Location Preferences

• Areas Willing to Work*
  Virginia BeachChesapeakeNorfolkPortsmouthSuffolkHamptonNewport News
• Services You Are Willing to Provide*
  CompanionshipHousekeepingLaundry / IroningMeal PreparationErrands / Shopping / TransportationPersonal CareMedication RemindersDementia / Alzheimer’s CareActivities (games, crafts)
• Do you have a valid driver’s license?*
  YesNo
• Do you have current auto insurance?*
  YesNo
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• Client Preferences

• Willing to work with pets?*
  YesNo
• If yes: Cats / Dogs
• Willing to work in a smoking environment?*
  YesNo
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• Job-Related Skills

• Relevant Training or Certifications*
• Previous Senior Care Experience*
• What do you enjoy most about working with seniors?*
• What do you enjoy least about working with seniors?*
• What personal rewards do you gain from senior care?*
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• Education

• Highest Level of Education Completed*
  GEDHigh SchoolVocational / TechnicalCollege / University
• School Name*
• City / State*
• Major / Subject*
• Years Attended*
• Graduate?*
  YesNo
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• Work History

• For each employer*
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• Background & Security

• States & Counties lived in (last 7 years)*
• Any moving traffic violations?*
  YesNo
• If yes, explain
• Any felony or misdemeanor convictions?*
  YesNo
• If yes, details
• Ever listed on a child abuse registry?*
  YesNo
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• References (3 Required – Non-Relatives)

  For each reference:
• *
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• Uploads

• Resume Upload*
  Browse Files

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• Certifications *
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• *
  I certify that the information provided is true and complete and authorize background and motor vehicle checks.
• *
  I understand employment is at-will and contingent upon background verification.
• Digital Signature*
• Submission Date
   -Month -DayYear

  Date
• Submit ApplicationSubmit Application
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