Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Lawanda Carvin
Created: 01/03/2020
Other names under which employment may be verified:  
Updated: January 8, 2020

Home Address
Street Address
327 W 76th ST APT 2
Unit/Suite Number
City ST/Zip
Chicago , IL 60620
Home Phone
Mobile Phone
7089826180
Alternate Phone
Email Address

Have you ever worked for us before?   No
If no, how did you hear about us? Indeed
Rate of pay desired.   $13-$16
Do you have a valid driver’s license?   No
Do you have access to a car? No

I am able to work client who has or lives with:
Family
Yes
Hospice
Yes
Cats
Yes
Dogs
Yes
Smoker
Yes
What languages do you speak?   
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  Addus Helathcare

How many years have you worked as a professional caregiver?  4
What percent of your previous case work has been for an agency?  20
Please explain how you will contribute to strengthen the Water Tower Nursing team.

I will contribute to strengthen the Water Tower Nursing team by obtaining my past accomplishments with working caregiving/healthcare field.

Please share one or more personal or professional experiences you have had as a caregiver.

I have worked with a few companies as a caregiver where I helped residents with activities of a daily living. Also with residents with old age, disabilities, and diseases.

Availability

Days   No
Nights   Yes
Weekdays   Yes
Weekends   No
Live-in   No
Can you travel outside the city of Chicago to work?   No

Education

High School   Perspectives High School of Technology
Location:   Chicago, Illinois
Did you graduate?   Yes
Subjects Studied   Technology

College   
Location:   
Did you graduate?   
Degree:   

Other:   Phalanx Family Services
Location:   Chicago, Illinois
Did you graduate?    Yes
Degree:   Certificate of Comy

Special awards you earned or courses you have taken.
106 hours of theory and laboratory. 40 hours of clinical.

Military Service

U.S. Military or Naval Service   No
Military branch and rank at discharge:   

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
Addus Healthcare
Phone
773-396-5600
Address

2335 95th ST

Supervisor
Job Title
Homemaker
Salary or Rate of Pay
$13.00
Responsibilities
Responsible for household, such as doing the dishes, laundry, and tidying up the house. Plans meals for client, create shopping lists, purchases groceries, and prepare meals
From
08/30/2019
To
06/03/2019
Reason for Leaving
Started school
May we contact this employer?  Yes

Company Name
Brookdale Senior Livivng
Phone
773-880-2960
Address

2960 N Lakeshore Drive

Supervisor
Erika Boltz
Job Title
Personalized Living (CNA)
Salary or Rate of Pay
10.35
Responsibilities
Assist with bathing, dressing, and medication reminders. Closely monitor residents to make sure their okay. Provide companion time and wellness checks. Provide care for residents’ pets if any.
From
06/10/2014
To
02/03/2016
Reason for Leaving
Maternity
May we contact this employer?  Yes

 

REFERENCES & ACCEPTANCE

Thank you for entering your employment history in Part Two. Before proceeding, could you please explain any gaps in your work history.
I went on maternity leave. The other jobs I had didn’t relate to this field. I later got a job as a homemaker, then I went back to school.
Character References
Please provide the names and contact information for three persons, not related to you, whom you have known for at least one year.
Name
Wanda Harris
Phone
(312) 837-7828
Address
Relationship
Associate

Name
Vanessa Reed
Phone
(773) 587-4885
Address
Relationship
Associate (classmate)

Name
Lawrence Williams
Phone
(312) 690-1761
Address
Relationship
Associate
Additional Information
Feel free to add any notes or additional information to your application in the space provided below.
No additional notes provided.
Thank you for entering your employment history. If gaps exist in your employment history, please explain the gaps here.
I went on maternity leave. The other jobs I had didn’t relate to this field. I later got a job as a homemaker, then I went back to school.
Additional Certifications
No additional certifications or licenses provided.

Have any of your certifications or licenses been suspended or revoked?  
If yes, explain.  
Resume Upload (optional)
If hired, would you be able to provide a copy of your Social Security Card?* (IDPH requirement)
Yes

I certify that the information contained in this application is true and correct to the best of my knowledge and I understand that falsification of this information is grounds for refusal to hire, or if hired, termination of my employment.

I agree that my employment is at-will and may be terminated or an offer of employment may be withdrawn by Water Tower Nursing and Home Care, Inc. (WTN) at any time, with or without notice, and for any lawful reason.

I understand that as a condition of employment and for continued employment, WTN may require periodic drug testing. I understand WTN will use the information gathered on this employment application to conduct background checking and will contact my references and agree to such references giving WTN any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise. I hereby release WTN, its shareholders, officers, directors, employees and agents from any an all liability for any damage that may result from the collection or utilization of such information in connection with evaluating my potential employment.

I understand if hired, I will be required to produce documentary evidence proving that I am currently authorized to work in the United States. I understand my continued employment is contingent upon providing proof of continuing work authorization upon expiration of any documents provided at time of hire. I understand I will have to provide a copy of my Social Security card upon hire as required by the Illinois Department of Public Health (IDPH).

I understand and agree that no representative of WTN has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to foregoing, unless it is in writing and signed by WTN’s President.

Accepted by
Lawanda Carvin

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
January 3, 2020
This application has been submitted and can no longer be edited.