Golden Pathways Home Care LLC

Thank you for your interest in Golden Pathways Home Care. Please complete the application below. Our team will review your information and contact you regarding next steps.

Golden Pathways Home Care LLC - Application

Compassionate Care . Trusted Support . Peace of Mind .
Thank you for your interest in Golden Pathways Home Care. Please complete the application below. Our team will review your information and contact you regarding next steps.

Golden Pathways Home Care is an equal opportunity employer. We consider applicants for all positions without regard to race, color, religion, gender, national origin, age, disability, or and other protected status.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Employment Type:

Full TimePart TimeWeekendsMorningsEveningsOn-Call
Pay Rate / Salary Expectations:

"What is your desired hourly pay rate?"
"What pay rate are you seeking?"

$16-$18/hr$18-$20/hr
"If other, please specify desired rate"
"Are you open to different pay rates based on experience and duties?"

YesNo
Work Availability:

Please check the days you are available to work and indicate the hours you can work.
What days are you available to work?

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
"What shifts are you available for?"

Morning (6a-12pm)Afternoon (12pm-6pm)Evening (6pm-10pm)OvernightFlexible
Maximum Hours Per Week:

10-20 hours20-30 hours30-40 hours40 hours
Additional Availability: Are you willing to work in multiple client homes if needed?

YesNo
"Do you have reliable transportation?"

YesNo
Employment History:

Please list your three most recent employers, starting with the most recent.
Most Recent Employer:
Company Name:
Position Held:
Dates Employed:
Supervisor Name:
Company Phone Number:
Reason for Leaving:
May we contact this employer? Yes or No
Company Name:
Position Held:
Dates Employed:
Supervisor Name:
Company Phone Number:
Reason for Leaving:
May we contact this employer? Yes or No
Company Name:
Position Held:
Dates Employed:
Supervisor Name:
Company Phone Number:
May we contact this employer? Yes or No
Professional References:

Please provide two professional references who can speak to your work ethic and and experience.
Name:
Relationship:
Phone Number:
Email:
Name:
Relationship:
Phone Number:
Email:
Background Information:
Have you ever been convicted of a crime?

YesNo
If yes, please explain:
Skills (Caregivers Only): Please check experience you have:

Bathing AssistanceDressing AssistanceToileting AssistanceMeal PreparationLight HousekeepingCompanionshipMedication RemindersTransfer/ Mobility Assistance
Do you have a valid driver's license?

YesNo
Driver's License Number:
State Issued:
Are you willing to transport clients (If applying for caregiver)?

YesNo
Emergency Contact:
Name:
Relationship:
Phone Number:
Education:
High School / GED:
School Attended:
City/ State:
"Do you have a High School Diploma or GED?"

YesNo
"If yes, please list the name of the school or program"
Additional Education / Training:

"If yes, please list the name of the school or program"
College Attended:
Degree or Certification:
"How many years of college have you completed"

None1 Year2 Years3 Years4+ Years
Degree Earned (if applicable)"
Certifications (Caregivers):

CPR CertifiedFirst Aid CertifiedFingerprint Clearance CardCaregiver Certification (If applicable)
Background Check Authorization:

I authorize Golden Pathways Home Care LLC to conduct a background check as part of the employment process.
Applicant Signature:
Date:

MonthDayYear
Date
Applicant Statement:

I certify that the information provided in this application is true and completed to the best of my knowledge. I understand that false information may result in disqualification or termination of employment.
Applicant Signature:
Date:

MonthDayYear
Date
Should be Empty:

Golden Pathways Home Care LLC - Application

Pay Rate / Salary Expectations:

Work Availability:

Employment History:

Most Recent Employer:

Professional References:

Background Information:

Emergency Contact:

Education:

Additional Education / Training:

Background Check Authorization:

Applicant Statement: