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EMPLOYMENT APPLICATION
Shepherd's Touch Homecare
is An Equal Opportunity Employer
Personal Information
Name
*
First Name
Middle Initial
Last Name
Address
*
Street Address
Street Address Line 2
City
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Washington
West Virginia
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State
Zip Code
E-mail
*
Confirmation Email
example@example.com
Phone
*
Format: (000) 000-0000.
Date of Birth
*
Please select a month
January
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Month
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Day
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2026
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1920
Year
Gender
*
Male
Female
Are you authorized to work in the U.S?
*
Yes
No
Are you above 18 years of age?
*
Yes
No
How did you hear about us?
Facebook
Website
Google
Referral
Languages spoken
Emergency contact
*
List names and phone numbers of all emergency contacts
Education
Degree/Diploma
Enter your degree or diploma earned
Certificate #
Enter certificate # if available
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Availability for work
Are you currently employed?
Yes
No
Current occupation
Years experience
Type of Position applying for
*
Caregiver
Other
Date you can start?
*
-
Month
-
Day
Year
Date
Expected Salary/Hourly rate
*
What shifts are you available to work?
*
Rows
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Day Shift
Night Shift
Noc Shift
Live-In
Are you able to work with clients with the following:
*
Cats
Dogs
Smokers
Other
Experience
List positions held, duties and experience.
Skills
Companion Care & Safety
Alzheimer's
Dementia
Meal Prep/Clean Up
Feeding
Light Houskeeping
Laundry
Medication Reminders
Transportation
Bathing (Reg/Bed/Sponge Bath)
Dressing/Grooming
Incontinence
Ambulation
Transfer Assist
Oral Care
Shaving Assistance
Assist with PT Exercises
Assist with Prosthesis
Hospice
Willing to work with pets
Speaks fluent english
Transportation
Do you have a reliable transportation?
*
Yes
No
Driver's License #
State Issued
Expiration Date
/
Month
/
Day
Year
Enter date of expiration
Are you willing to assist client in all transportation needs?
*
Yes
No
Distance willing to travel?
*
Please Select
Under 10 miles
Over 10 miles
Abuse Investigation
Have you ever been investigated for abuse, neglect or domestic voilence?
*
Yes
No
If you answered yes, please explain below
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Work History
Current employer
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
*
Supervisor's Name
*
Position Held
*
Start Date
-
Month
-
Day
Year
End Date
-
Month
-
Day
Year
Reason for Leaving
*
May we contact this employer for a reference?
*
Yes
No
Employer 2
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
*
Supervisor's Name
*
Position Held
*
Start Date
-
Month
-
Day
Year
End Date
-
Month
-
Day
Year
Reason for Leaving
*
May we contact this employer for a reference?
*
Yes
No
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References
Work Reference 1
*
Name of Reference
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Work Reference 2
*
Name of Reference
Phone Number
*
Format: (000) 000-0000.
Email
*
Personal reference
*
Name of Reference
Phone Number
*
Format: (000) 000-0000.
Email
*
Submit Application:
By clicking the submit button below, I authorize former employers, references and any other individual/organizations to provide information to CareGivers LLC, and I hereby release and discharge any of the above and release CareGivers LLC from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary. I agree to a criminal background check, fingerprint, physical examination if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with CareGivers LLC. I further understand that, if hired, I may be required to provide proof that I am a citizen of the United States or currently authorized to work in the United States. In consideration of my employment, I agree to conform to the hired company's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, by either me or the company's option. "I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatements of fact, I am subject to disqualification, dismissal, or other action pursuant to employment agency policy and procedure, and subject to criminal penalties as prescribed by law."
Signature
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*
Date
*
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