Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
jeffrey lazaro
Created: 01/14/2020
Other names under which employment may be verified:  
Updated: January 15, 2020

Home Address
Street Address
4151 williamsburg ct
Unit/Suite Number
City ST/Zip
glenview, IL 60025
Home Phone
Mobile Phone
7734564573
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us? online search
Rate of pay desired.   20
Do you have a valid driver’s license?   Yes
Do you have access to a car? Yes

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?   english, tagalog
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  mae morgan agency

How many years have you worked as a professional caregiver?  15
What percent of your previous case work has been for an agency?  10
Please explain how you will contribute to strengthen the Water Tower Nursing team.

by doing excellent work and treating my clients as family

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

i adjust myself defends on their need and im always ready to care for them 24/7 even for emergencies

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   meycauayan college
Location:   philippines
Did you graduate?   Yes
Subjects Studied   graduated high school

College   harbor college
Location:   wilmington, california
Did you graduate?   No
Degree:   pre nursing

Other:   CNA
Location:   des planes, illinois
Did you graduate?    Yes
Degree:   certified nursing assistant

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
mae morgan agency
Phone
310-217-9000
Address

carson california

Supervisor
janice
Job Title
caregiver
Salary or Rate of Pay
15 per hour
Responsibilities
deals with hospice, copd, dimentia, cancer, dialysis, parkinson’s disease patients
From
05/01/2009
To
04/30/2013
Reason for Leaving
patient passed away and decided to move to chicago
May we contact this employer?  Yes

Company Name
ruth landsman
Phone
410-913-3976
Address

8950 pottawattami drive , skokie 60076

Supervisor
Job Title
caregiver
Salary or Rate of Pay
200 per day
Responsibilities
trach care, alzheimer’s care, meal prep, medications, activities with daily living
From
12/16/2013
To
03/20/2019
Reason for Leaving
patient passed away
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.
No gaps or no explanation provided.
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
ruth landsman
Phone
410-913-3976
Address
maryland
Relationship
employer

Name
robin barker
Phone
909-938-9157
Address
california
Relationship
employer

Name
alex matzig
Phone
703-309-1208
Address
chicago
Relationship
friend
Additional Information
Feel free to add any notes or additional information to your application in the space provided below.

i have training in dialysis technician and cna certification

Thank you for entering your employment history. If gaps exist in your employment history, please explain the gaps here.
No gaps or no explanation provided.
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)
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
JEFFREY LAZARO

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
January 15, 2020
This application has been submitted and can no longer be edited.