Job Application
Thank you for your interest in working for HomeCare by Design. Please tell us about yourself.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Email
example@example.com
Language
English only
French only
Bilingual (prefer English)
Bilingual (prefer French)
Have you reached legal working age?
Yes
No
Have you been employed by us before?
Yes
No
Do you have any Friends or Relatives employed by us?
Friend
Relative
If so, please list their names
How did you hear about us?
Job Bank
Company Employee
Client
Newspaper
Facebook
LinkedIn
Kijiji
Indeed
Career Beacon
Other
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Desired Employment
What position are you applying for?
Caregiver
Care Coordinator
What region?
Saint John & surrounding area
Fredericton & surrounding area
Moncton & surrounding area
Desired rate of pay
How many hours/day would you prefer to work?
How many hours/week would you prefer to work?
Availability for work (choose all that apply)
Days
Evenings
Nights
Weekends
Weekends
Holidays
Live in
Date available for work
-
Month
-
Day
Year
Date
What are your long term professional goals?
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Match Criteria
Please select all that match your skills and preferences
General
Dementia experience
Hospice/Palliative experience
Incontinence experience
Personal care experience
Rehab experience
Medication administration experience
Cooking healthy meals
Ok with client smoking
Transfers
Gait belt experience
Hoyer lift experience
Max client weight for transfers
Pets
OK with Cats
OK with Dogs
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Education & Training
High School
Yes
No
Year Graduated
College/University
Yes
No
Degree Received
Year Graduated
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Certification & Credentials
Please check all that apply. Make note of any that have expired and add any other notes as applicable.
Car Insurance
CPR Certification
Driver's License
Driver's License Record
First Aid Certification
Flu Vaccine
Food Handling Certification
Police Record Check
Registered Nurse
LPN License
Medical Clearance
Social Development Record Check
Notes
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Employment History
Please provide your most recent positions of employment.
Employer
Phone Number
-
Area Code
Phone Number
Supervisor
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
Employer
Phone Number
-
Area Code
Phone Number
Supervisor
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
+ Additional Employer
Employer
Phone Number
-
Area Code
Phone Number
Supervisor
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Start Date
-
Month
-
Day
Year
Date
End Date
-
Month
-
Day
Year
Date
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Professional References
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relationship
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