Caregiver Job Application


APPLICANT INFORMATION

Application Status
Draft
Name (First, Middle, Last)
Jessica Equia Adam
Created: 02/10/2020
Other names under which employment may be verified:  
Updated: February 10, 2020

Home Address
Street Address
2452 W Ardmore
Unit/Suite Number
Apt G
City ST/Zip
Chicago, IL 60659
Home Phone
6303879368
Mobile Phone
7734583895
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us? Google search
Rate of pay desired.   25
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, tagalog
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  

How many years have you worked as a professional caregiver?  10
What percent of your previous case work has been for an agency?  1
Please explain how you will contribute to strengthen the Water Tower Nursing team.

I am reliable,dependable and have a work ethics.

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

They treat me like a family.

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   Manticao High School
Location:   Philippines
Did you graduate?   Yes
Subjects Studied   High School

College   Liceo de Cagayan University
Location:   Philippines
Did you graduate?   Yes
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
All is Well
Phone
8472080622
Address

5601 King Arthur CRT #6
Westmont, IL 60559

Supervisor
Jeanette Dojoles
Job Title
Caregiver
Salary or Rate of Pay
$18
Responsibilities
Taking care of Alzheimer’s patient
From
02/08/2010
To
05/08/2017
Reason for Leaving
Moved to the city
May we contact this employer?  Yes

Company Name
Private Home
Phone
7733502533
Address

3180 N Lake Shore Dr
8A

Supervisor
Elanor Reiter
Job Title
Caregiver
Salary or Rate of Pay
$25
Responsibilities
Taking care of Alzheimer’s patient
From
05/22/2017
To
12/09/2019
Reason for Leaving
He 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
Phone
Address
Relationship

Name
Phone
Address
Relationship

Name
Phone
Address
Relationship
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?  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)

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
Disclaimer has not been accepted. Job Application will not be processed until the Disclaimer is accepted.

PART FIVE – APPLICATION SUBMISSION

Application Status
Draft
Date Submitted