Position applying for:
Have you ever been convicted of a felony? No Yes
If Yes, please provide details:
Many caregiver positions require the caregiver to transport a client.
Do you have dependable transportation? No Yes
Number of hours you would like to work:
Times you are available to work:
Any times not available to work:
Can we call you to fill an emergency shift? No Yes
Starting with high school, please list the schools you have attended and degrees, if any.
Discuss any training or experience working with the elderly.
What would you like most about working with the elderly?
What would you like least about working with the elderly?
Please indicate if you have assisted with or performed the following tasks for seniors.
Please go back at least 5 years and tell us about your work history.
May we contact your current employer? No Yes
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.
