Senior Independence Home Care — Quick Applicant Interest Form
Share your availability and experience so we can match you with current opportunities.
Contact
Full name
*
First Name
Last Name
Mobile phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Home city
*
ZIP code
*
Preferred contact method
*
Text
Call
Email
Full Employment Application — Optional Fast Track
Work preferences
Position
Caregiver
RN supervisory visits
Cities willing to work in
*
Livonia
Westland
Canton
Plymouth
Northville
Dearborn
Dearborn Heights
Redford
Wayne
Garden City
Belleville/Van Buren Township
Ypsilanti
Ann Arbor
Taylor
Allen Park
Southgate
Lincoln Park
Wyandotte
Romulus
Brownstown/Woodhaven
Monroe
Other
Select places you are willing to accept shifts, not only where you live.
Other cities
Maximum travel time each way
*
Up to 15 minutes
Up to 30 minutes
Up to 45 minutes
Up to 60 minutes
Flexible
Days available
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Times available
*
Morning
Afternoon
Evening
Overnight
Exact hours or schedule restrictions
Desired weekly hours
*
Under 20
20–30
30–40
Flexible
Start availability
*
Immediately
Within two weeks
Later
If later, date or details
Can you reliably arrive at assigned shifts?
*
Yes
No
Depends on location
Experience
Caregiving experience
*
None yet
Less than 1 year
1–3 years
More than 3 years
Languages you’re comfortable using with clients
Current certifications
CNA
Home Health Aide training certificate
CPR
First Aid
LPN license
RN license
None currently
Other
Upload résumé or relevant training certificates (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Select current credentials only. Credentials will be verified during hiring. You can optionally upload a résumé or training certificates near the end of the form.
Credential names and expiration dates
List the same credentials you selected above and expiration dates if known; enter Not sure if needed.
RN license state
RN license number
Already completed our AxisCare application?
Yes
No
Not sure
Anything else about your availability
Relevant education or caregiver training
Most recent employer (or no prior employment)
Most recent job title
Employment dates
Main duties
May we contact your current employer?
Yes
No
Not applicable
Previous employer, job title and dates (optional)
Professional reference 1 — name, relationship and phone or email
Professional reference 2 — name, relationship and phone or email
Relevant caregiving skills
Application accuracy acknowledgment
*
Applicant typed signature
Application date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Consent and submission
What would you like to do?
Submit my quick prescreen and request a callback
Continue with the full employment application
Acknowledgment
I certify that the information I provided is true, complete, and accurate to the best of my knowledge, and I understand this is not an offer of employment.
SMS consent
I agree to receive text messages from Senior Independence Home Care regarding my employment application, recruiting follow-up, interview scheduling, and related employment communications. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for help. Consent to receive text messages is not a condition of employment.
Privacy Policy
SMS Terms
Authorized to work in the US?
*
Yes
No
Submit prescreen
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