Application

APPLICATION

Please submit an application below if you are interested in working for our company.

Address:
City:
State:
Zip Code:
Experience:
Alzheimer’s/DementiaHospiceIncontinence CareTransferringAmbulation AssistBathing/Shower AssistBed bathBed bound assistBoard transfersDressing AssistFeeding AssistGait BeltHoyer LiftHospiceIncontinence CareToileting AssistLight HousekeepingMeal PrepMedication RemindersOral Hygiene AssistShaving AssistOK with client’s who smokesOK with dogsOK with catsPACE
Education:
High School:
Year Graduated:
College
Graduated?YesNo
Vehicle Insurance
Expiration:
TB/Chest X-Ray
Expiration:
CNA License
Expiration:
CPR License
Expiration:
First Aid Certification
Expiration:
Driver’s License
Expiration:
Employment History:
Please provide your most recent positions of employment.
1.Employer:
Phone:
Supervisor:
Address:
City:
State:
Zip Code:
Date Employed:
From:
To:
2.Employer:
Phone:
Supervisor:
Address:
City:
State:
Zip Code:
Date Employed:
From:
To:
3.Employer:
Phone:
Supervisor:
Address:
City:
State:
Zip Code:
Date Employed:
From:
To:
Professional References:
Please provide professional references.
Name:
Phone Number:
Name:
Phone Number:
Name:
Phone Number:
Additional Information:
Are you at least 18 years of age? YesNo
Have you ever worked for A Care Partner in the past? YesNo
How did you hear about A Care Partner?
Current Employee
Name:
IndeedCraigslistFacebookLinked In
Other
Are you a US Citizen?YesNo
If hired, can you provide proof of your legal eligibility to work in the United States?YesNo
If no, please explain:
Have you ever been convicted of a felony?YesNo
If no, please explain:

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
I understand to become an employee of A Care Partner, I must have a valid Driver's License, pass a background check and drug screen, and provide proof of citizenship in compliance with US form (I-9). Proof of citizenship can be shown by providing any one of the following: Social Security Card, Birth Certificate, or US Passport.
By submitting this application, I authorize all former employers to release any and all employment information they may have about me to A Care Partner. I release all persons or companies from any liability or responsibility for providing such information.