Caregiver Application

Caregiver Application
Which are you applying for?
Full Name

First NameLast Name
Contact Email
example@example.com
Contact Email
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Your Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a reliable form of transportation?
Vehicle Make & Model
Please list all of the states you have lived in the past five years.
Emergency Contact

First NameLast Name
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What is your relationship to your emergency contact?
Which position are you applying for?
Please list any skills, trainings, and/or certifications that you think are relevant to the position.
Availability
Days of Availability
What times are you available on these days?
What date can you start?

MonthDayYear
Date
Desired Salary
Are you currently employed?
If so, may we contact your employer?
Name of High School you attended
Did you graduate?
Year of Completion
Name of College/University (if applicable)
Years Completed
Did you graduate?
Year of Completion
Please list any other schooling- started and completed (if applicable)
Please list any degrees, certifications, and licenses obtained (if applicable)
Have you ever been convicted of a crime (excluding misdemeanors or traffic offenses) that would exclude you from working with the elderly or disabled?
If yes, please explain.
Please list three references that are of no relation to you and that you have known for a minimum of one full year.
Reference #1

First NameLast Name
Reference #1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reference #1 Email Address
example@example.com
Relationship to Reference #1
Reference #2

First NameLast Name
Reference #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reference #2 Email Address
example@example.com
Relationship to Reference #2
Reference #3

First NameLast Name
Reference #3 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reference #3 Email Address
example@example.com
Relationship to Reference #3
Do you have any professional references? If yes, please list the names and phone numbers.
Please list your most recent four employers- starting with the most recent.
Name of Company #1
Type of Business
Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Supervisor

First NameLast Name
Position
Please list job duties at Company #1.
Date Started

MonthDayYear
Date
Date Finished

MonthDayYear
Date
Reason for Leaving
Name of Company #2
Type of Business
Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Supervisor

First NameLast Name
Position
Please list job duties at Company #2.
Date Started

MonthDayYear
Date
Date Finished

MonthDayYear
Date
Reason for Leaving
Name of Company #3
Type of Business
Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Supervisor

First NameLast Name
Position
Please list job duties at Company #3.
Date Started

MonthDayYear
Date
Date Finished

MonthDayYear
Date
Reason for Leaving
Name of Company #4
Type of Business
Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Supervisor

First NameLast Name
Position
Please list job duties at Company #4.
Date Started

MonthDayYear
Date
Date Finished

MonthDayYear
Date
Reason for Leaving
How did you hear about Elder House/Complete Home Care?
I authorize the investigation of all statements contained herein, and the checking of references, from previous employers or any entity whom they deem to be an appropriate reference. I understand that questions may be asked about my educational background. attendance, history, character, personality, disciplinary information, and the reason for separation from any former employee. It is also understood that any information given to Complete Home Care is to be used for the purpose of determining my acceptability for employment with Complete Home Care.
Signature
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