Caregiver Job Application


APPLICANT INFORMATION

Application Status
Draft
Name (First, Middle, Last)
America Gilbert
Created: 02/08/2020
Other names under which employment may be verified:  
Updated: February 12, 2020

Home Address
Street Address
601 E 32nd St
Unit/Suite Number
Apt 310
City ST/Zip
Chicago, IL 60616
Home Phone
13125239053
Mobile Phone
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us?
Rate of pay desired.   Market Rate
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
No
What languages do you speak?   english
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  Medical professional

How many years have you worked as a professional caregiver?  40
What percent of your previous case work has been for an agency?  20
Please explain how you will contribute to strengthen the Water Tower Nursing team.

Utilizing my experiences in ICU, ER, HOME HEALTH,Hospice etc.and most of all my passion for a profession that I never get tired of doing.

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

Being a part of a code blue team. The md called off the code after trying for 45mins The spouse came in later and was beating him in the chest for dying he woke up it became what we call Cardiac Thump in the 70's.

Availability

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

Education

High School   West Memphis Sr. High
Location:   West Memphis Ark.
Did you graduate?   Yes
Subjects Studied   Basic

College   Kennedy king college
Location:   Chicago Il.
Did you graduate?   Yes
Degree:   Associate in Nursing

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
Michael Reese Hospital
Phone
Closed
Address

2900 south Ellis ave
Chicago,Il 60616

Supervisor
Mary Truitt
Job Title
Picu Rn
Salary or Rate of Pay
31.00/hr
Responsibilities
Charge/preceptor/ caregiver
From
05/09/1988
To
08/29/2008
Reason for Leaving
Hospital closing. Work from1977 to 1988 as critical care aid til I graduated Nursing School.
May we contact this employer?  Yes

Company Name
Lara bida Children Hospital
Phone
7733636700
Address

6700 promontory Drive
Chicago Il. 60617

Supervisor
Urfrancia Green
Job Title
ER Charge RN
Salary or Rate of Pay
42.99/he
Responsibilities
Charge/preceptor/ caregiver
From
05/05/1992
To
04/30/2013
Reason for Leaving
Retired
May we contact this employer?  Yes

Company Name
Mercy Hospital Chicago
Phone
3125672000
Address

2525 south Michigan ave.
Chicago,Il. 60616

Supervisor
Anita'Allen
Job Title
Staff RN
Salary or Rate of Pay
45.99/he
Responsibilities
Charge/preceptor/ caregiver
From
01/05/2015
To
Reason for Leaving
Still employed
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 worked from 1972-2013 and returned to work 2015 after beating Non Hodgkins Lymphoma. Currently working at Mercy.
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
Marilyn Young
Phone
Address
Relationship
Friend coworker

Name
Helena Bernin
Phone
Address
601 E 32nd St
Relationship
Friend/Neighbor

Name
Marren Culberson
Phone
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.
I worked from 1972-2013 and returned to work 2015 after beating Non Hodgkins Lymphoma. Currently working at Mercy.
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
America Gilbert

PART FIVE – APPLICATION SUBMISSION

Application Status
Draft
Date Submitted