Become a Valued Member of Our Care Team EMPLOYMENT APPLICATION Personal InformationName: First Initial Last: Date of Birth: MM slash DD slash YYYY Gender: Male Female Address: Street: Apartment: City: State: Zip: Phone Home:Cell:Email Address: Language (What languages do you speak?): Emergency Contact (Name & Phone Number of Person to contact in the event of an emergency): Education:Diploma: Certificate: Degree: Other: Current CPR?: Expiration Date: MM slash DD slash YYYY Restrictions:Work: Limitations: Are there any work limitations that you may have? Briefly describe the limitations:Type of Position(s) Preferred: Home Makers Personal Care Companion Live-In Office Live-in care usually requires that you stay iin a client’s home continuously for 3-4 days at a time every week. Indicate which shifts you will accept: Weekdays (Monday a.m. to Friday a.m.) Weekends: (Friday a.m. to Monday a.m.) Hours & Days Available for Work:Untitled Full-time Part-time Short-notice Split Shift Indicate Days and List Hours Available for Work:Sunday From: Sunday To: Monday From: Monday To: Tuesday From: Tuesday To: Wednesday From: Wednesday To: Thursday From: Thursday To: Friday From: Friday To: Saturday From: Saturday To: TransportationPrivate Vehicle: Other: (Specify) Do you have a valid Driver’s License? Are you willing to transport clients in your private vehicle? Do you have adequate vehicle insurance? Are you willing to escort a client in their own vehicle? Are you willing to escort a client on public transportation? Employment Information (Most Recent Position) Company Name: Address: Telephone No:Supervisor’s Name: Position Held: Length of Employment: Reason for Leaving: Company Name: Address: Telephone No:Supervisor’s Name: Position Held: Length of Employment: Reason for Leaving: Company Name: Address: Telephone No:Supervisor’s Name: Position Held: Length of Employment: Reason for Leaving: References Personal #1 Name: Address: Telephone No:Email Address: Nature of Friendship (friend, co-worker, etc): Personal #2Name: Address: Telephone No:Email Address: Nature of Friendship (friend, co-worker, etc.) : Have you ever been investigated for abuse, neglect or domestic violence? Yes No If “yes”, explain:Untitled I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained in this application, as required. Additionally, I authorize former employers, references, and any other individual/organizations to provide information to Dedicated Hearts & Hands and I hereby release and discharge any of the above and Dedicated Hearts & Hands from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary. I agree to a physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with the Agency. I also understand that employment, for certain positions, may be conditional upon successful completion of a substance abuse screening test and a criminal background check. If further understand that, if hired, I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States. Attach Resume:Max. file size: 100 MB.Applicant’s SignatureDate: MM slash DD slash YYYY
