Employment Application Packet
Direct Care Worker / Caregiver - Pennsylvania
Applicant: Please complete all applicable sections. Do not provide a Social Security number, medical diagnosis, disability information, or other protected medical information on this application. Required onboarding clearances and health documentation are handled separately.
POSITION INFORMATION
Position Applied For
Date of Application
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Desired Start Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employment Desired (Full-Time / Part-Time / PRN)
Preferred Weekly Hours
Preferred Service Area / County
APPLICANT INFORMATION
Full Legal Name
First Name
Last Name
Preferred Name (optional)
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
Format: (000) 000-0000.
Email Address
example@example.com
Are you at least 18 years old?
Yes
No
Are you legally authorized to work in the United States?
Yes
No
Will you now or in the future require employer sponsorship for employment authorization?
Yes
No
Absolute Home Care Solutions, LLC is an equal opportunity employer. Employment decisions are made without unlawful discrimination or retaliation. Reasonable accommodations are available for qualified applicants as required by law.
ABSOLUTE HOME CARE SOLUTIONS, LLC | EMPLOYMENT APPLICATION
Availability & Caregiving Profile
AVAILABILITY
AVAILABILITY
Rows
Morning
Afternoon
Evening
Overnight
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Available for holidays?
Yes
No
Available for short-notice shifts?
Yes
No
EXPERIENCE & SERVICE SKILLS
Companionship
Personal care / ADL assistance
Meal preparation
Light housekeeping
Laundry
Errands / shopping
Respite care
Mobility / transfer assistance
Dementia / memory support
Medication reminders (non-administration)
Other relevant skills / languages
Describe your home care / caregiving experience
ABSOLUTE HOME CARE SOLUTIONS, LLC | EMPLOYMENT APPLICATION
TRANSPORTATION - COMPLETE ONLY IF DRIVING IS AN ESSENTIAL JOB DUTY
Valid driver's license?
Yes
No
Reliable transportation?
Yes
No
Current auto insurance?
Yes
No
Driver's license state
Expiration
Do not submit copies of driver's license or insurance until requested during the hiring/onboarding process.
Employment & Education History
EMPLOYMENT HISTORY - MOST RECENT FIRST
Employer 1
Employer Name
Employer Phone
Format: (000) 000-0000.
Job Title
Supervisor
First Name
Last Name
Start Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Duties
Reason for Leaving
Employer 2
Employer Name
Employer Phone
Format: (000) 000-0000.
Job Title
Supervisor
First Name
Last Name
Start Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Duties
Reason for Leaving
Employer 3
Employer Name
Employer Phone
Format: (000) 000-0000.
ABSOLUTE HOME CARE SOLUTIONS, LLC | EMPLOYMENT APPLICATION
Job Title
Supervisor
First Name
Last Name
Start Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Duties
Reason for Leaving
EDUCATION / TRAINING
Highest Level Completed
School / Program
City / State
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Year Completed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relevant caregiving, direct care, CNA, HHA, CPR/First Aid, dementia, or other training
Care is where Home is • Pennsylvania Non-Medical Home Care
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