Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Cynthia Avitia
Created: 01/19/2020
Other names under which employment may be verified:  Cynthia Perez
Updated: January 19, 2020

Home Address
Street Address
6431 S Keeler Ave
Unit/Suite Number
City ST/Zip
Chicago, IL 60629
Home Phone
7734907257
Mobile Phone
7734907257
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us?
Rate of pay desired.   Open
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, spanish
Do you have any caregiver training from other home services agencies?  No
If yes, explain.  

How many years have you worked as a professional caregiver?  0
What percent of your previous case work has been for an agency?  0
Please explain how you will contribute to strengthen the Water Tower Nursing team.

I have 12 years of customer service experience, 5 years of which I was managing. I am a fast learner with a very strong work ethic.

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

I volunteered at a home for Alzheimer’s patients and I loved it. I was able to listen to them, assist them and keep them company. I’ve been in the service industry, but I’m eager to step in to the health care field.

Availability

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

Education

High School   Lane Tech
Location:   IL
Did you graduate?   Yes
Subjects Studied   

College   Wright College
Location:   IL
Did you graduate?   No
Degree:   

Other:   
Location:   
Did you graduate?   
Degree:   

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
Cozy Corner Restaurant
Phone
+1 (224) 805-0772
Address

5454 Harlem Ave

Supervisor
Elias Betondo
Job Title
Store Manager
Salary or Rate of Pay
$19.50
Responsibilities
From
03/01/2015
To
01/16/2020
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.
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
Carolina Ramirez
Phone
1 (224) 316-0422
Address
Relationship
Friend

Name
Jennifer Inskip
Phone
+1 (773) 419-1105
Address
Relationship
Coworker

Name
Danny
Phone
+1 (224) 281-9646
Address
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.
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?  
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
Cynthia Avitia

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
January 19, 2020
This application has been submitted and can no longer be edited.