• Caregiver Employment Application

    Thank you for your interest in joining Five Star Companion Care. Please complete the application below and provide accurate information regarding your professional caregiving experience, employment history, availability, and references.

  • Personal Information

  • Date of Application*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred Contact Method*
  • Do you have a previous address?*

  • Position Information

  • Have you lived in Pennsylvania continuously for the past two years?*
  • Are you at least 19 years old?*
  • Are you legally authorized to work in the U.S.?*
  • Have you previously worked for Five Star Companion Care?

  • Caregiving Experience

  • Requirement
  • Do you meet the 1-year verifiable professional caregiving experience requirement?*
  • Graduated?
  • Completed?
  • Graduated?
  • Caregiving Experience – Select all that apply

  • Employment History

  • Two Most Recent Employers*
  • Reliable transportation*

  • Identification

  • Expiration Date*
     - -
  • Current automobile insurance
  • Did you receive a copy of the Job Description?*
  • Can you perform the essential functions of the position?*
  • Services willing to provide*
  • Willing to work in a home with pets?*
  • Cats?*
  • Dogs?*
  • Willing to work in a home where a client smokes?*
  • Please list your previous employers or agencies below. Include as many entries as needed.

  • Education & Training

  • Relevant credentials held

  • Availability

  • Transportation

  • Do you have reliable transportation?*
  • Do you have a valid driver’s license?*
  • Which counties are you willing to work in?*
  • Are you comfortable working around pets?*

  • References

  • Three (3) references required. No relatives or family members.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Caregiver Questions

  • Are you comfortable with the following duties?*

  • Direct Care Worker Availability

  • AVAILABILITY ACKNOWLEDGMENT I understand that my availability may be considered when making work assignments and that hours are not guaranteed. I will promptly notify the Agency of any changes to my availability. I understand that assignments and hours may depend on my availability, qualifications, competency, participant needs and preferences, and available cases. Nothing in this acknowledgment creates a contract of employment or alters my at-will employment status. I understand that I may provide only authorized non-medical services within my assigned duties and demonstrated competency. In a medical emergency, I will call 911 and follow emergency procedures.
  • Available Start Date
     - -
  • Preferred Availability
  • Days Available
  • Available Start Time
     - -
  • Available End Time
     - -
  • Are you available for Overnight shifts?
  • Are you available for Live-In assignments?
  • Are you willing to accept temporary fill-in hours until your preferred hours become available?
  • Are you available to be on call for additional income?

  • Applicant Certification & Acknowledgment

    I certify that the information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that providing false, misleading, or incomplete information may result in disqualification from employment consideration or termination of employment if hired. By submitting this application, I acknowledge that I have read, understand, and agree to the certification above.
  • Date*
     - -

  • Office Use Only

    Hired Date: ____________________ References Checked: ☐ Yes ☐ No By: ____________________
  • Should be Empty: