Employment App

Step 1: Personal Information

First Name*

Last Name*

2nd Initial

Date of Birth*

Street Address*

Apartment/Unit

City*

State & Zip*

Cell Phone*

Home Phone

Other Phone

Email Address*

Social Security Number*

Gender*MaleFemale

Languages spoken

Local Emergency Contact*

Out-of-Area Contact

Step 2: Education & Limitations

Formal Education

Informal/Other Education

First Aid Certified?YesNo

CPR Certified?YesNo

CPR Expiry Date

Food Safety Course?YesNo

Work LimitationsHearingSpeechLiftingHealthPhysicalEmotionalOther

Describe any limitations

Step 3: Availability

Availability TypeFull-timePart-timeShort-noticeSplit Shift

Min Hours/Day

Max Hours/Day

Sunday Hours

Monday Hours

Tuesday Hours

Wednesday Hours

Thursday Hours

Friday Hours

Saturday Hours

Step 4: Work Preferences & Transportation

Type of Work SeekingHome MakerPersonal CareCompanionLive-InOther

Live-In Shifts AcceptedWeekdays (Mon a.m. to Fri a.m.)Weekends (Fri a.m. to Mon a.m.)

Clients Not Willing/Able to Work WithDementias/Alzheimer'sMental RetardationPhysical DisabilitiesBehavioral DisordersChildrenHIV Positive/AidsSmokersPetsFemalesMalesMedicinal Marijuana Users

Duties Not Willing/Able to PerformAmbulationBathing/ShoweringGroomingPersonal HygieneHousekeepingLaundryMeal PreparationShoppingTransportationBladder CareBowel CareMedication RemindingFeedingOral CareDressing

ExperienceAmbulationBathingGroomingHousekeepingLaundryMeal PreparationShoppingTransportationBladder CareBowel CareMedication RemindingFeedingDressingFriendly ReassuranceSocializationToileting

Restricted in geographical location?YesNo

Explain

Transportation TypePrivate VehicleBusBikeOther

Valid Driver's License?YesNo

License State

Valid Vehicle Insurance?YesNo

Insurance Agency

Willing to transport clients (own vehicle)?YesNo

Willing to drive client's vehicle?YesNo

Willing to escort in client's vehicle?YesNo

Willing to escort on public transport?YesNo

Step 5: References & Residency History

Work Reference #1

Company Name

Address

Phone & Email

Supervisor's Name

Position Held

Length of Employment & Reason for Leaving

Work Reference #2

Company Name

Address

Phone & Email

Supervisor's Name

Position Held

Length of Employment & Reason for Leaving

Personal References

Ref #1 Name & Relationship

Contact Info

Ref #2 Name & Relationship

Contact Info

Former Name(s) and Date(s) used

Investigated for abuse/neglect?YesNo

If yes, explain

Other cities/states/dates of residency in last 10 years

Step 6: Authorizations & Signature

I certify that the answers given are true and complete. I authorize investigation of all statements
contained in this application, and background checks (Criminal, Sex Offender, Employment, Education,
License, MVR, Medical Suitability, Drugs/Alcohol). I have read, understood, and agree to follow the
Cell Phone Policy (no personal use during client care, HIPAA compliance, no photos/videos of clients).

I have read, understood, and agree to all terms, background check authorizations, and cell phone policies above.

Please Sign Below

Date*