Date: 12/8/2016

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 Number
Mobile Phone
Email *

Section 1 - General Information

Number Question Effective Date Expiration Date
1. Job Type? (required)  
 
 
2. Briefly tell us about your caregiving experience and why you are a wonderful caregiver.  
 
3. Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? (required)  
     
4. Do you have reliable transportation? (required)  
     
5. How did you hear about us?  
     

Section 2 - Employment Verification

Number Question Effective Date Expiration Date
1. Are you a U.S. citizen? (required)  
     
2. Are you authorized to work in the U.S.? (required)  
 
 
 

Section 3 - Education

Number Question Effective Date Expiration Date
1. Name of High School, Trade School or University  
     
2. Did you graduate? (required)  
     

Section 4 - Do you have any Certifications/Licenses/Titles

Number Question Effective Date Expiration Date
1. Caregiver/Homemaker  
     
2. HHA  
     
3. CNA  
     
4. Years of Experience? (required)  
  (Numeric Answer Only)    

Section 5 - Current/Last Employer

Number Question Effective Date Expiration Date
1. Current/Last Employer: (required)  
     
2. State:  
     
3. Start Date  
     
4. End Date (if applicable)  
     
5. Position Held (required)  
 
6. Supervisor's Name (required)  
     
7. Office Phone (required)  
     
8. Is this your current employer? (required)  
     
9. What was your current/ending hourly rate? (required)  
  (Numeric Answer Only)    

Section 6 - Travel

Number Question Effective Date Expiration Date
1. How far are you willing to drive to a shift? (required)  
 
 
 

Section 7 - Availability

Number Question Effective Date Expiration Date
1. Are you avail week days?  
     
2. Please indicate which days you are available:  
     
3. Are you available during the week either evenings and/or nights?  
     
4. Please list the days you are available for evening/nights  
     
5. Which shifts are you available?  
 
 
 
6. Are you available Saturdays (if yes, please choose preferred shift)  
 
 
 
7. Are you available Sundays (if yes, please choose preferred shift)  
 
 
 



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.