Name:
Position Applying For:
Caregiver
Office Staff
Address:
Years at Current Address:
Own or Rent:
Previous Address:
Telephone:
Email Address:
Social Security Number:
Are You Are Legal Citizen Of The United States of America?
Emergency Contact Information
Emergency Contact Name:
Address:
Telephone:
Relationship:
Criminal Background
Have you ever been convicted of a felony or misdemeanor?
If yes, please describe:
Transportation
Do you have reliable transportation?
Driver's License Number:
State:
Vehicle Make:
Vehicle Model:
License Plate Number:
Insurance Company:
Agent Name:
Agent Phone Number:
Policy Number:
Work Hours
Hours Available:
Hours Desired:
Hours Unavailable:
Are you available for emergencies?
Are you available for a 24-hour live-in position?
Required Hourly Wage:
Comments:
Education
High School:
City/State:
Dates:
College:
City/State:
Dates:
Other:
City/State:
Dates:
Degrees/Certifications:
Special Skills or Training:
Names, Addresses, Telephone Numbers For Any Non-Profit/Volunteer Organizations Affiliated With
Experience
Discuss all training or experience with seniors/elderly individuals:
What do you like the most about working with seniors/elderly individuals?
What do you find the least desirable about working with seniors/elderly individuals?
Employement History
Please go back at least 5 years
Employer 1
Company Name:
Job Title
From:
To:
Duties:
Supervisor:
Phone:
Reason For Leaving:
May We Contact This Employer?
Employer 2
Company Name:
Job Title
From:
To:
Duties:
Supervisor:
Phone:
Reason For Leaving:
May We Contact This Employer?
Employer 3
Company Name:
Job Title
From:
To:
Duties:
Supervisor:
Phone:
Reason For Leaving:
May We Contact This Employer?
Employer 4
Company Name:
Job Title
From:
To:
Duties:
Supervisor:
Phone:
Reason For Leaving:
May We Contact This Employer?
Current/Previous Landlords
Landlord 1
Name:
Address:
Number Of Years:
Telephone:
Landlord 2
Name:
Address:
Number Of Years:
Telephone:
Landlord 3
Name:
Address:
Number Of Years:
Telephone:
Landlord 4
Name:
Address:
Number Of Years:
Telephone:
Personal References
Reference 1
Name:
Address:
Years Known/Relationship:
Telephone:
Reference 2
Name:
Address:
Years Known/Relationship:
Telephone:
Reference 3
Name:
Address:
Years Known/Relationship:
Telephone:
Reference 4
Name:
Address:
Years Known/Relationship:
Telephone:
Certification and Release
I Certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions or misrepresentation of facts will result in rejection of this application and/or discharge at any time during employment. I authorize Visiting Angels to verify any and all information contained in this application, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release and information concerning my background & 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 and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment.
Restrictive Convenant
I agree not to do business directly with any individual or business entity that Visiting Angels has introduced to me or by entering into employment with such individuals or businesses.
Please enter your e-mail address here to certify your agreement to the terms outlined above.
