Veteran Care Companions Employment Application

Relevant Information
Date You Can Start*

MonthDayYear
Salary Desired*
Position Interested In (check all that apply):*

Full TimePart TimeTemporaryFloater
THEFT QUESTION: Do you have a conviction (misdemeanor or felony) for any theft related crimes, including, but not limited to, shoplifting, criminal conversion, burglary, robbery, attempted robbery, identity theft, embezzlement, check forgery, petty theft, grand theft, larceny, fraud, receiving stolen property, carjacking, etc. This does not include any crime that has been successfully expunged. We are only asking about crimes still on your record. *
If you answered "YES" to the theft crime question, please explain below:
CRIMINAL HISTORY QUESTION: State law prohibits any home care agency from employing or contracting with any person who has been convicted of a crime involving theft, battery, murder, manslaughter, sex crime, exploitation of an endangered adult, abuse or neglect of a child and failure to report battery, neglect, or exploitation of an endangered adult or dependent. We perform a Nationwide background check. Do you currently have any conviction (misdemeanor or felony) for any of the aforementioned crimes that would bar you from working or contracting as a caregiver? This does not include any crime that has been successfully expunged. We are only asking about crimes still on your record. *
If you answered "YES" to the criminal background question, please explain below:
Do you have an active, valid Indiana Driver's license with no violations and accidents?

Yes, I have a valid Indiana driver's license with no violations or accidentsI have a valid driver's license but have violations / accidents in the last 3 yearsI have a valid driver's license but have violations / accidents more than 3 years agoI do not have a valid Indiana driver's license and seeking a non-driving position

Skills/Qualifications:
Why do you want to be a caregiver for veterans?*
List three words that describe your personality:*
What skills and experience do you have that are useful in the role of a caregiver? Feel free to be as in depth as possible.*
CPR Certification Status*

I have attended in person CPR training in the past and my certification is still validI have attended in person CPR training in the past but my CPR cert has expiredI have a valid CPR certification but I have never attended in person trainingI have never held a valid CPR certification
GROOMING REQUIREMENTS: Our personal Care Assistants help clients with their personal hygiene as part of their role. The amount of assistance will vary from client to client but may include, bathing, assisting with bathing, assisting with oral hygiene, assisting with combing hair, assisting with applying lotion and deodorant and dressing. Do you understand this is part of the job and are you willing to perform these duties if hired? *
TOILETING REQUIREMENTS: Our personal Care Assistants may have to help a client with their toileting and elimination. This includes assisting to and from the bathroom, assisting with clean up, assisting with Depends or diapers, assisting with bedside commodes, etc. Do you understand this is part of the job and are you willing to perform these duties if hired? *
LIGHT HOUSEKEEPING REQUIREMENTS: Our personal Care Assistants perform light housekeeping to support our clients in maintaining a clean, hygienic, and safe home. Light housekeeping will include washing dishes, sweeping, mopping, vacuuming, dusting, cleaning and sanitizing bathrooms, changing bed linen, doing laundry, taking out trash, etc. Do you understand this is part of the job and are you willing to perform these duties if hired? *
MEAL PREP REQUIREMENTS: Our personal Care Assistants help clients with their nutrition as part of job responsibilities. This includes, but not limited to, meal planning, meal prepping, cooking, plating the food, grocery shopping, visiting pantries, etc. PCAs are expected to prepare hot meals for clients as part of their duties. Do you understand this is part of the job and are you willing to perform these duties if hired? *
List any additional relevant training you have received, including caregiving training, health & safety training, dementia training, culinary training, etc.*
Anything else you would like to share:*
Include links to your social media profiles, so we can get to know you better: *

Education:
High School*
Name of High School Attended
Graduated High School?*
College*
Name of College/University Attended
College Status?*
List of other professional training, licenses or certifications:*
i.e. Home Health Aide, CNA, LPN, Medical Assistant, etc.

Mandatory Job History
Employer #1 *
i.e. Name of Family
Position*
Your job title
Employer Start Date*

MonthDayYear
Employer End Date*

MonthDayYear
Duties and Responsibilities*
Please include an in-depth job description
Reason for Leaving*
Employer #2
i.e. Name of Family
Position
Your job title
Start Date

MonthDayYear
End Date

MonthDayYear
Duties and Responsibilities
Please include an in-depth job description
Reason for Leaving
Employer #3
i.e. Name of Family
Position
Your job title
Start Date

MonthDayYear
End Date

MonthDayYear
Duties and Responsibilities
Please include an in-depth job description
Reason for Leaving

References:

Please include at least three; at least 1 must be a former employer. A signed reference form is required for each reference. Please click the link and sign a reference form for each reference.
Reference # 1*
Full name of reference
Reference # 1 - Authorization Form

Please complete a reference form for the aforementiond applicant.

For a professional reference (former employer), click here

For a personal reference, click here
Did you complete the authorization form for Reference #1 ?

YesNo

References:

Please include at least three; at least 1 must be a former employer. A signed reference form is required for each reference. Please click the link and sign a reference form for each reference.
Reference # 2*
Full name of reference
Reference # 2 - Authorization Form

Please complete a reference form for the aforementiond applicant.

For a professional reference (former employer), click here

For a personal reference, click here
Did you complete the authorization form for Reference #2 ?

YesNo

References:

Please include at least three; at least 1 must be a former employer. A signed reference form is required for each reference. Please click the link and sign a reference form for each reference.
Reference # 3*
Full name of reference
Reference #3 - Authorization Form

Please complete a reference form for the aforementiond applicant.

For a professional reference (former employer), click here

For a personal reference, click here
Did you complete the authorization form for Reference #3 ?

YesNo

Attachments
Optional: Please Upload Your Resume

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Optional: Upload Copies of any Professional Certifications or Licenses you hold

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Optional: Please Upload Copy of your CPR Certification

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Optional: Please Upload Copy of your TB Skin Test Results

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Optional: Please Upload Proof of Auto Insurance

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Optional: Please Upload Copy of DD214 (*Veterans only*)

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I certify to Veterans Care Companions that the information provided on this employment application are true and complete to the best of my knowledge, and I consent Veteran Care Companions in processing personal data about me for purposes related to my employment. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my termination of employment.
Applicant Signature

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Caregiver Application

Relevant Information

Skills/Qualifications:

Education:

Mandatory Job History

References:

References:

References:

Attachments