Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Alicia Ignacio Luciano
Created: 01/03/2020
Other names under which employment may be verified:  None
Updated: January 23, 2020

Home Address
Street Address
2816 West Waveland Avenue
Unit/Suite Number
2nd floor
City ST/Zip
Chicago, IL 60618
Home Phone
None
Mobile Phone
7735923506
Alternate Phone
None

Have you ever worked for us before?   No
If no, how did you hear about us? A friend recommended me
Rate of pay desired.  
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
No
Dogs
No
Smoker
No
What languages do you speak?   
Do you have any caregiver training from other home services agencies?  
If yes, explain.  Custome Home Care

How many years have you worked as a professional caregiver?  7
What percent of your previous case work has been for an agency?  80
Please explain how you will contribute to strengthen the Water Tower Nursing team.

Be a good,caring professional and knowledgeable caregiver

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

Doing my best at all times and right care for the patient as well as being respectful.

Availability

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

Education

High School   Completed
Location:   Manila, Philipines
Did you graduate?   Yes
Subjects Studied   

College   Completed
Location:   Manila, Philippines
Did you graduate?   Yes
Degree:   BSN

Other:   
Location:   
Did you graduate?    Yes
Degree:   BSN

Special awards you earned or courses you have taken.

Military Service

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

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
Custom Home Care
Phone
773 561 4663
Address

2716 Peterson Avenue, Chicago ,
Illinois 60618

Supervisor
Job Title
Caregiver
Salary or Rate of Pay
13/hour
Responsibilities
To be a professional and knowledgeable caregiver
From
11/21/2018
To
01/04/2020
Reason for Leaving
I am still employed with the agency.
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 still have family in the Philippines so i visited them especially my 78 years old mother
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
Jeannie Parry
Phone
949 632 2059
Address
1989 Abbotsford Barrington Chicago, Il 60010
Relationship
Daughter of my my former patients, Mary and Don Littwin

Name
Bernice Kathrein
Phone
847 707 7687
Address
2150 West Gold Road Hoffman Estate Chicago, Il 60169
Relationship
Daughter of my Former patient, Be rnice Kathrein

Name
Nora Winsberg
Phone
312 316 7413
Address
Brookdale N. Sheridan
Relationship
Daughter of my former patient, Mary Winsberg
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 still have family in the Philippines so i visited them especially my 78 years old mother
Additional Certifications
No additional certifications or licenses provided.

Have any of your certifications or licenses been suspended or revoked?  No
If yes, explain.  
Resume Upload (optional)
No Resume Uploaded
If hired, would you be able to provide a copy of your Social Security Card?* (IDPH requirement)
No

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
Alicia Ignacio Luciano

PART FIVE – APPLICATION SUBMISSION

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