Date: 4/23/2014

Application Form

Assistance Home Care

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Personal Information

First Name * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License #
Mobile Phone
Email *

Section 1 - General Information

Number Question Effective Date Expiration Date
1. Maiden name/ Other names used? (required)  
     
2. Job Type? (required)  
 
 
 
 
3. Date Available? (required)  
     
4. Can you provide documentation of a driver's license and auto insurance? (required)  
     
5. Drivers License Expiration Date: (required)  
     
6. Auto Insurance Expiration Date: (required)  
     
7. Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? (required)  
     
8. If yes, please explain. If no, enter "n/a". (required)  
 
9. Do you have at least two years of caregiving experience in a professional/homecare enviroment (required)  
     
10. How did you hear about Assistance Home Care? (required)  
 

Section 2 - Employment Verification

Number Question Effective Date Expiration Date
1. Are you a U.S. citizen? (required)  
     
2. If you are not a U.S. citizen, please indicate VISA type and number.  
     
3. Are you authorized to work in the U.S.? (required)  
 
 
 
 

Section 3 - Education

Number Question Effective Date Expiration Date
1. Name of High School: (required)  
     
2. Location of High School: (required)  
     
3. Did you graduate? (required)  
     
4. Years Attended (From/To): (required)  
     
5. Additional Education (vocational, undergraduate, etc.)  
     
6. If yes, please list the name of the school and years attended (From/To)  
 

Section 4 - Other Training: Certifications/Licenses

Number Question Effective Date Expiration Date
1. Certifications/ License (required)  
 
 
 
 
 
2. How many years have you been doing HOME CARE? (required)  
     

Section 5 - Current/Most Current Employment

Number Question Effective Date Expiration Date
1. Current Employer: (required)  
     
2. Address:  
     
3. City: (required)  
     
4. State:  
     
5. Zip Code:  
     
6. Start Date: (required)  
     
7. End Date: (required)  
     
8. Hours Worked:  
 
 
 
9. Position/Title: (required)  
     
10. Describe Your Responsibilities: (required)  
 
11. Supervisor's Name/Title: (required)  
     
11. Supervisor's Phone: (required)  
     
13. Reason for Leaving: (required)  
 
14. May we contact? (required)  
     

Section 6 - Employment History

Number Question Effective Date Expiration Date
1. Last Employer: (required)  
     
2. Address:  
     
3. City: (required)  
     
4. State:  
     
5. Zip Code:  
     
6. Start Date: (required)  
     
7. End Date: (required)  
     
8. Hours Worked:  
 
 
 
9. Position/Title: (required)  
     
10. Describe Your Responsibilities: (required)  
 
11. Supervisor's Name/Title: (required)  
     
12. Supervisor's Phone: (required)  
     
13. Reason for Leaving: (required)  
 
14. May we contact? (required)  
     

Section 7 - Reference 1

Number Question Effective Date Expiration Date
1. Name: (required)  
     
2. Company: (required)  
     
3. Phone: (required)  
     

Section 8 - Reference 2

Number Question Effective Date Expiration Date
1. Name: (required)  
     
2. Company: (required)  
     
3. Phone: (required)  
     

Section 9 - Emergency Contact Information

Number Question Effective Date Expiration Date
1. First Name: (required)  
     
2. Last Name: (required)  
     
3. Address: (required)  
     
4. City: (required)  
     
5. State: (required)  
     
6. Zip Code: (required)  
     
7. Phone 1: (required)  
     
8. Phone 2:  
     
9. Relationship: (required)  
     

Section 10 - Travel

Number Question Effective Date Expiration Date
1 What areas are you willing to travel to for an assignment? (required)  
     
2 How far are you willing to drive to a shift? (required)  
 
 
 
 
 

Section 11 - Availability

Number Question Effective Date Expiration Date
1. Are you available Days? (required)  
     
2. Are you available Nights? (required)  
     
3. Are you available to work Weekend Days? (required)  
     
4. Are you available to working weekend nights? (required)  
     
5. Are you available to work long shifts up to 12 hours + (required)  
     
6. Are you available for short shifts (3-5 hours)? (required)  
     
7. Are you available to work Live in shifts (24 hours)? (required)  
     
8. If you are available for live in shifts can you committ to working 2-3 consecutive days as a live in? (required)  
     
9. Please explain what your desired schedule is (required)  
 

Section 12 - Other

Number Question Effective Date Expiration Date
1 Can you stoop, bend and lift up to 25 lbs? (required)  
     
2 Are you willing to work with small/Medium dogs? (required)  
     
3 Are you willing to work with large dogs? (required)  
     
4 Are you willing to work with cats? (required)  
     
5 Are you willing to work with a smoker? (required)  
     



I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.