Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Sylvia V Hicks
Created: 01/09/2020
Other names under which employment may be verified:  
Updated: January 22, 2020

Home Address
Street Address
3154 west 64th street
Unit/Suite Number
1st floor
City ST/Zip
Chicago, IL 60629
Home Phone
3128901696
Mobile Phone
3128901696
Alternate Phone
3128901696

Have you ever worked for us before?   No
If no, how did you hear about us?
Rate of pay desired.   15.00
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.  A better living

How many years have you worked as a professional caregiver?  01
What percent of your previous case work has been for an agency?  05
Please explain how you will contribute to strengthen the Water Tower Nursing team.

I will be a good team player very reliable and a caring hard worker.

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

I was such a kind very good worker for a couple of clients that them and they always give very good report too my agency.

Availability

Days   Yes
Nights   Yes
Weekdays   Yes
Weekends   Yes
Live-in   Yes
Can you travel outside the city of Chicago to work?   Yes

Education

High School   King
Location:   Chicago
Did you graduate?   No
Subjects Studied   Math

College   
Location:   
Did you graduate?   No
Degree:   

Other:   
Location:   
Did you graduate?   
Degree:   

Special awards you earned or courses you have taken.
I,m a C.N.A

Military Service

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

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
Mylife Home Health
Phone
6304626700
Address

218 west willow ave

Supervisor
Kathy Muller
Job Title
C.N.A/private duty
Salary or Rate of Pay
15.00
Responsibilities
Vital signs, med reminder. Bathing etc.
From
03/09/1998
To
11/13/2015
Reason for Leaving
Lost business in building
May we contact this employer?  Yes

Company Name
Symphony of Broneville
Phone
3128425000
Address

3400 east Indian

Supervisor
Tilasha
Job Title
Schduler
Salary or Rate of Pay
14.75
Responsibilities
Private Duty,MED.reminder,escort, bathing, vital signs etc.
From
03/27/2018
To
11/20/2019
Reason for Leaving
Lost business in building
May we contact this employer?  Yes

Company Name
Regency Home health care
Phone
8478646400
Address

1600 Chicago Ave

Supervisor
Kathy Mooly
Job Title
C.N.A/private duty
Salary or Rate of Pay
15.00
Responsibilities
Med reminder escort
From
05/16/2012
To
08/18/2016
Reason for Leaving
May we contact this employer?  Yes

Company Name
A Better living
Phone
No longer available
Address

523 west Madison

Supervisor
Kate
Job Title
Care giver
Salary or Rate of Pay
14.00
Responsibilities
Cleaning.cooking,bathing etc.
From
11/06/2013
To
12/23/2015
Reason for Leaving
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.
The Agency no longer there
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
Jamine Ward
Phone
3127095390
Address
7931 south cornell
Relationship
Friend

Name
Myra Hancock
Phone
3127783069
Address
7632 east stony
Relationship
Friend

Name
Twanda Gordon
Phone
7086298784
Address
708 east Marquette
Relationship
Friend
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.
The Agency no longer there
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)
No Resume Uploaded
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
Sylvia Hicks

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
January 22, 2020
This application has been submitted and can no longer be edited.