Application

APPLICATION

Thank you for your interest in working for our agency.
Please submit the application below to apply for a position as a caregiver.

Name:*
Middle Initial:
Address:*
E-mail:*
Mobile Phone:
-
Home Phone:
-
Are you a US citizen?
Have you ever been convicted of a felony?
Availability (M//T/W/TH/F/SAT/SUN) (days, nights, overnights):

Match Criteria:


Not all skills are required of new caregivers. 

Insured Automobile?
Dementia Experience?
Hospice Experience?
Incontinence Experience?
Ok with client smoking?
Transfer Experience?
Are you willing to work with a client who has a pet?

Education & Training:


High School:
Did you graduate?
College:
College experience:
Degree received:

References & Employment History:


Please provide professional references.

Name
Company
Relationship
Number
-
Name(2)
Company(2)
Relationship(2)
Number(2)
-
Name(3)
Company(3)
Relationship(3)
Number(3)
-

Please provide recent position of employment.


Company:
Supervisor:
Contact #:
Job Title:
Date from:
Date to:
Hourly Rate:
Reason for leaving:

Please provide recent position of employment.


Company:(2)
Supervisor
Contact #
-
Job Title
Date from
Date to
Hourly Rate
Reason for leaving

Additional Information:


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.

Please verify that your a human: