Mikily Home Care Employment Application
Employment application for caregiver and office roles at Mikily Home Care LLC. Please complete all required fields and provide optional uploads only if available.
Applicant Information
Full Legal Name
*
First Name
Middle Name
Last Name
Preferred Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Street Address
*
City
*
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Other
Date Available to Start
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Position Applying For
Position Applying For
*
Caregiver
Homemaker
Companion
Personal Care Aide
Live-In Caregiver
Office/Admin
Other
Employment Type Desired
*
Full-Time
Part-Time
Per Diem
Live-In
Weekend
Overnight
Availability by Day and Shift
*
Rows
Morning
Afternoon
Evening
Overnight
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Eligibility
Legally authorized to work in the United States
*
Yes
No
Age 18 or older
*
Yes
No
Can provide required documents if hired
*
Yes
No
Reliable transportation
*
Yes
No
Valid driver's license
*
Yes
No
Willingness to complete background/CORI screening as permitted by law
*
Background screening
CORI screening
Both
Other
Experience
Years of home care/caregiver experience
*
Previous home care agency experience
*
Yes
No
Experience working with seniors
*
Yes
No
Experience working with people with disabilities
*
Yes
No
Experience with dementia/Alzheimer's care
*
Yes
No
Experience providing mobility assistance
*
Yes
No
Experience with meal preparation
*
Yes
No
Experience with light housekeeping
*
Yes
No
Experience providing companionship
*
Yes
No
Types of care experience
*
Medication reminders
Live-in care
Respite care
Personal care assistance
Errands and transportation
Other
Certifications and Training
Certifications held
*
HHA
CNA
PCA
CPR
First Aid
Dementia Training
Other
Issuing organization
Certification date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Expiration date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Training details
Upload certifications or resume (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Work History
Employer Name 1
*
Job Title 1
*
Dates Employed 1
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supervisor/Contact 1
First Name
Last Name
Reason for Leaving 1
Employer Name 2
*
Job Title 2
*
Dates Employed 2
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supervisor/Contact 2
First Name
Last Name
Reason for Leaving 2
References
Reference 1 Name
*
First Name
Middle Name
Last Name
Reference 1 Relationship
*
Reference 1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 1 Email Address
*
example@example.com
Reference 2 Name
*
First Name
Middle Name
Last Name
Reference 2 Relationship
*
Reference 2 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 2 Email Address
*
example@example.com
Reference 3 Name
*
First Name
Middle Name
Last Name
Reference 3 Relationship
*
Reference 3 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference 3 Email Address
*
example@example.com
Skills Checklist
Personal care assistance
Yes
No
Bathing and dressing support
Yes
No
Mobility support
Yes
No
Transfers
Yes
No
Meal preparation
Yes
No
Light housekeeping
Yes
No
Laundry
Yes
No
Errands and shopping
Yes
No
Companionship
Yes
No
Appointment reminders
Yes
No
Documentation and service notes
Yes
No
Applicant Questions
Why do you want to work with Mikily Home Care?
*
Describe your caregiving approach.
*
Do you have any scheduling limitations? Please explain.
Certification and Consent
Equal Opportunity Statement
Electronic Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Application
Submit Application
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