Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Merlina Tippit
Created: 01/20/2020
Other names under which employment may be verified:  
Updated: January 20, 2020

Home Address
Street Address
5606 High Timber Lane, Indianapolis, IN, USA
Unit/Suite Number
4501 Liberty Blvd. Westmont,IL
City ST/Zip
Indianapolis, IN 46235
Home Phone
Mobile Phone
317-512-2576
Alternate Phone
773-620-8355

Have you ever worked for us before?   No
If no, how did you hear about us? from a friend
Rate of pay desired.   n/a
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
No
Hospice
Yes
Cats
No
Dogs
No
Smoker
No
What languages do you speak?   
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  Home Care Angels

How many years have you worked as a professional caregiver?  08
What percent of your previous case work has been for an agency?  98
Please explain how you will contribute to strengthen the Water Tower Nursing team.

To give my service compassionately and respectfully to the clients.
To show good demeanor and coming on time to work.

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

Being a caregiver for years i learned to be more patient and understanding.
Being professional caregiver i learned to respect the privacy of the client and family as well.

Availability

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

Education

High School   San Carlos National high
Location:   Tukuran ZDS- Philippines
Did you graduate?   Yes
Subjects Studied   HS-Diploma

College   MSU-IIT
Location:   Iligan City-Philippines
Did you graduate?   Yes
Degree:   Diploma in civil Engineering Technology

Other:   
Location:   
Did you graduate?   
Degree:   

Special awards you earned or courses you have taken.
Basic Nursing Assistant completed Oct.12,2013

Military Service

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

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
Self-employed
Phone
630-688-7392
Address

Niles, IL

Supervisor
Job Title
private caregiver
Salary or Rate of Pay
n/a
Responsibilities
personal care,errands,prepare meals,assist exercises,light house keeping & companionship
From
08/20/2015
To
10/20/2017
Reason for Leaving
client is passed away
May we contact this employer?  Yes

Company Name
Indepence4Senior
Phone
708-254-8186
Address

5 W 2nd St,Hinsdale,IL

Supervisor
Joann
Job Title
caregiver
Salary or Rate of Pay
n/a
Responsibilities
assist client with oxygen and assist exercises, remind meds, prep meals, personal care & companionship
From
05/20/2013
To
09/10/2019
Reason for Leaving
moved
May we contact this employer?  Yes

Company Name
Home Care Angels
Phone
847-824-5221
Address

2720 S River Rd. Des Plaines,IL

Supervisor
Joyce
Job Title
caregiver
Salary or Rate of Pay
n/a
Responsibilities
personal and oral care,remind meds,prepare meals, assist ROM, & companionship
From
06/20/2014
To
09/22/2017
Reason for Leaving
moved
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.
there are assignments only short term and some i shifted to better schedules that work for my personal needs.
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
Aurora Lucero
Phone
312-450-9522
Address
Chicago,IL
Relationship
friend

Name
Evah Clayton
Phone
630-242-018
Address
Relationship
landlady and friend

Name
Michelle Schofield
Phone
317-840-5060
Address
Indianapolis,IN
Relationship
staff/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.
there are assignments only short term and some i shifted to better schedules that work for my personal needs.
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
Merlina Neri Tippit

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
January 20, 2020
This application has been submitted and can no longer be edited.