Caregiver Application Form
Date:
-
Month
-
Day
Year
Date Picker Icon
In Person Interview date
Name
First Name
Last Name
Full Address:
Email:
example@example.com
SSN/SIN #
Phone:
Format: (000) 000-0000.
DOB:
-
Month
-
Day
Year
Date
Position you are applying for:
Do you have a First Aid/CPR certificate?
YES
NO
Certification Registration #
Expiry Date
-
Month
-
Day
Year
Date
Desired
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
wage amount:
Hourly Weekly Monthly Salary
Hourly
Weekly
Monthly
Salary
Can you work nights?
YES
NO
Can you work weekends?
YES
NO
Can you work holidays?
YES
NO
How many hours can you work weekly?
4-16
16-26
26-40
Type of employment desired:
FULL-TIME LIVE OUT
PART-TIME LIVE OUT
LIVE IN FULL TIME
ON CALL
What date are you available to start work?
-
Month
-
Day
Year
Date
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NOTES:
JOB 1
Name of Business/Employer:
Job Title/Position:
Employment Dates: Start [MM/YY]
-
Month
-
Day
Year
Date
End [MM/YY]
-
Month
-
Day
Year
Date
Phone/Email:
Location:
Person to Contact
Position in Company
Reason for Leaving Company:
Cana representative from our company contact your most recent employer?
YES
NO
JOB 2
Name of Business/Employer:
Job Title/Position:
Employment Dates: Start [MM/YY]
-
Month
-
Day
Year
Date
End [MM/YY]
-
Month
-
Day
Year
Date
Phone/Email:
Location:
Person to Contact
Position in Company
Reason for Leaving Company:
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Cana representative from our company contact this previous employer?
YES
NO
JOB 3
Name of Business/Employer:
Job Title/Position:
Employment Dates: Start [MM/YY]
End [MM/YY]
Phone/Email:
Location:
Person to Contact
Position in Company
Reason for Leaving Company:
Can a representative from our company contact this previous employer?
YES
NO
Do you currently hold a driver's licence?
YES
NO
What is your current mode of transportation?
Driver's License Number#
Location where the licence was issued
Licence Expiration Date [MM/DD/YY]
-
Month
-
Day
Year
Date
Are you willing to relocate job assignments?
YES
NO
Any driving accidents in the past three years?
YES
NO
How many?
If yes, please explain:
Any driving violations in the past three 3 yrs.?
YES
NO
How many?
If yes, please explain:
Check the technology devices that you use:
Cell
Computer
Tablet
Do you have a data plan on your mobile device?
YES
NO
Will you be willing to fill out a caregiver daily checklist after each visit?
YES
NO
Additional Notes:
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Reference 1
Name:
Connection:
Phone:
Format: (000) 000-0000.
Email
example@example.com
Have they been notified that they are a reference?
YES
NO
Reference 2
Name:
Connection:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Have they been notified that they are a reference?
YES
NO
Reference 3
Name:
Connection:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Have they been notified that they are a reference?
YES
NO
Reply from reference 1:
Reply from reference 2:
Reply from reference 3:
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Rows
LEVEL OF EDUCATION
NAME OF SCHOOL
PROGRAM
COMPLETED
COMPLETED
1
2
3
4
5
6
7
8
Should be Empty: