Caregiver Employment Application

Caregiver Employment Application

Complete this application for caregiver positions.
Applicant Information
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
ZIP
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Date of Application

MonthDayYear
Date
Position Applying For
Desired Schedule
Date Available to Start

MonthDayYear
Date
Desired Pay Rate
Eligibility and Background
Are you legally authorized to work in the United States?
Have you ever worked for this agency before?
If yes, explain your prior work for this agency
Have you ever been convicted of a crime?
If yes, explain the circumstances
Are you able to lift 25 pounds or more?
Education and Certifications
School/Program
Location
Degree/Certification
Year Completed
CNA - License Number
CNA - Expiration Date

MonthDayYear
Date
HHA - License Number
HHA - Expiration Date

MonthDayYear
Date
CPR - License Number
CPR - Expiration Date

MonthDayYear
Date
First Aid - License Number
First Aid - Expiration Date

MonthDayYear
Date
Other Certification/License - Name
License Number
Expiration Date

MonthDayYear
Date
Employment History
Employer #1 - Company Name
Employer #1 - Position Held
Employer #1 - Supervisor Name
Employer #1 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer #1 - Dates Employed
Employer #1 - Reason for Leaving
Employer #1 - Job Duties
Employer #2 - Company Name
Employer #2 - Position Held
Employer #2 - Supervisor Name
Employer #2 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer #2 - Dates Employed
Employer #2 - Reason for Leaving
Employer #2 - Job Duties
Caregiving Experience and Availability
Caregiving Experience

Other
Caregiving Experience - Other (describe)
Monday - Weekly Availability Hours
Tuesday - Weekly Availability Hours
Wednesday - Weekly Availability Hours
Thursday - Weekly Availability Hours
Friday - Weekly Availability Hours
Saturday - Weekly Availability Hours
Sunday - Weekly Availability Hours
References and Signatures
Reference #1 Name

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

First NameLast Name
Reference #2 Relationship
Reference #2 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Applicant Signature
Applicant Signature - Date

MonthDayYear
Date
Agency Representative Signature
Agency Representative Signature - Date

MonthDayYear
Date
Should be Empty:

Caregiver Employment Application

Applicant Information

Eligibility and Background

Education and Certifications

Employment History

Caregiving Experience and Availability

References and Signatures