Caregiver Employment Application

Employment Application

Senior Affordable Care — Please fill out the form completely.

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Section 1 – General Information

Job type applying for? *

Available Start Date? *

Emergency Contact

Emergency Contact Name *

Emergency Contact Number *

Availability: please fill out below

Monday *

Tuesday *

Wednesday *

Thursday *

Friday *

Saturday *

Sunday *

Can you provide documentation of a valid driver's license and auto insurance? *

Yes

Do you have reliable transportation? *

Yes

Do you understand that drug testing may be required? *

Yes

How many miles are you willing to drive for work? *

Section 2 – Employment Verification

Hourly rate expectations? *

Are you authorized to work in the U.S.? *

Yes

Have you ever worked in homecare before? *

Yes

Are you fluent in English (written and spoken)? *

Yes

Describe the type of care you provided and duties performed

Name and phone of family member to verify caregiving experience

Section 3 – Education and Certifications

Select an education or certification option *

If certified (CNA, MA, HHA), is your certification current?

Yes

High School Graduate or GED?

Yes

College?

Yes

College – years completed or degree received

Other certifications, skills, or training

Section 2 - Employment Verification

Hourly rate expectations? *

Are you authorized to work in the U.S.? *

Yes

Have you ever worked in homecare before? *

Yes

What type of duties have you performed?

Are you fluent in English written and spoken communication skills? *

Yes

Describe what type of care you provided and what duties you performed:

Name and phone number of family member to verify caregiving experience:

Section 3 - Education and Certifications

Please select an education or certification option: *

If you are a certified CNA, MA, or HHA: is your certification current?

Yes

Certification State (if certified):

High School Graduate or GED?

Yes

College?

Yes

College - years completed or degree received?

Other certifications, skills, or training?

Section 4 - Skills and Preferences

Have you received the appropriate training to perform transfers of care recipients? *

Yes

Are you able to transfer from bed to wheelchair, using your own body weight? *

Yes

Section 6 - Employee References (Professional)

Employer Name *

Address *

Phone Number *

Contact *

Start Date

End Date

Reason for Leaving

Job Title *

Wage *

May this person be contacted for a reference? *

Yes

Employer Name *

Address *

Phone Number *

Contact *

Start Date

End Date

Reason for Leaving

Job Title *

Wage *

May this person be contacted for a reference? *

Yes

Section 7 - Applicant's Statement

I hereby certify that I have not knowingly held back any information that might affect my chances for employment. I further certify that I personally completed this application. *

Yes

I hereby authorize Senior Love Care to thoroughly investigate my background, contingent on a satisfactory report. *

Yes

I understand that nothing in this application or interview creates a binding employment contract. *

Yes

I acknowledge that I have read and understand the preceding statements. *

Yes

Upload CV / Resume *

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.