Name (First, Middle, Last)

  Date

  Street Address

  Years at this address

  Email

  City

  State

  Zip

  Home Phone

  Cell Phone

  SSN

  Date of Birth

  Name

  Phone

  Address

  Relationship

  I am applying for a position as a

  I want to work in the following areas (Please be specific)

  Have you ever been convicted of a felony?    YES   NO

  If yes, please provide details

  Transportation: Many caregiver positions require the caregiver to transport a client.

  Do you have dependable transportation?  YES   NO

  Make and Model car

  License Plate #

  Driver License #

  Auto Insurance policy #

  Insurance Company

  Insurance Agent name

  Insurance Agent Phone

 Number of hours that you  would like to work

 Days/Times when you are  available to work

 Days/Times not available to  work

 Can you be called at the last  minute in case of  emergency?
    YES   NO

  Comments

  High School

  City/State

  Dates

  College

  City/State

  Dates

  Other

  City/State

  Dates

  Degrees/Certificates

  Special Skills or Courses

  Discuss any training or experience working with the elderly

  What would you/do you like most about working with the elderly?

  What would you/do you like least about working with the elderly?

  Employment History
  Please go back five (5) years and tell us about your work history. Use reverse side of sheet if additional space is   required.

  May we contact your current employer?     YES   NO

  Company

  From

  To

  Job Title

  Reason Left

  Duties

  Supervisor

  Phone

  Company

  From

  To

  Job Title

  Reason Left

  Duties

  Supervisor

  Phone

  Company

  From

  To

  Job Title

  Reason Left

  Duties

  Supervisor

  Phone

  Company

  From

  To

  Job Title

  Reason Left

  Duties

  Supervisor

  Phone

  Name

  Address

  Relationship/Years Known

  Local Phone #

  Name

  Address

  Relationship/Years Known

  Local Phone #

  Name

  Address

  Relationship/Years Known

  Local Phone #

  Name

  Address

  Relationship/Years Known

  Local Phone #

  Name

  Address

  Relationship/Years Known

  Local Phone #

  CERTIFICATION AND RELEASE: I certify that I have read and understand the application note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

  Signature

  Date