Caregiver Job Application


APPLICANT INFORMATION

Application Status
Draft
Name (First, Middle, Last)
oyun Siciliano
Created: 05/16/2020
Other names under which employment may be verified:  None
Updated: August 3, 2020

Home Address
Street Address
4541 N.Sheridan
Unit/Suite Number
Apt 303
City ST/Zip
Chicago, IL 60640
Home Phone
None
Mobile Phone
7087318871
Alternate Phone
Email Address

Have you ever worked for us before?   No
If no, how did you hear about us? Web site
Rate of pay desired.   14.5 -18
Do you have a valid driver’s license?   Yes
Do you have access to a car? No

I am able to work client who has or lives with:
Family
Yes
Hospice
Yes
Cats
No
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.  Open arms agency

How many years have you worked as a professional caregiver?  16
What percent of your previous case work has been for an agency?  50
Please explain how you will contribute to strengthen the Water Tower Nursing team.
Please share one or more personal or professional experiences you have had as a caregiver.

Yes

Availability

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

Education

High School   Mongolea
Location:   Ulaan bator
Did you graduate?   Yes
Subjects Studied   Yes

College   Ulaanbaatar
Location:   UB
Did you graduate?   Yes
Degree:   Bachelor

Other:   
Location:   
Did you graduate?    No
Degree:   

Special awards you earned or courses you have taken.
None

Military Service

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

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
Comfort Keepers
Phone
3124706070
Address

1 East Superior st, suite 210 Chicago il

Supervisor
Itay
Job Title
Caregiver
Salary or Rate of Pay
14.5-18
Responsibilities
Take care everything for people
From
To
Reason for Leaving
Still working with agency
May we contact this employer?  Yes

Company Name
Home Helpers
Phone
8472393969
Address

113 Fairfield Way,suite 302, bloomingdale il

Supervisor
Paula Moerschel
Job Title
Caregiver
Salary or Rate of Pay
14.5-18
Responsibilities
Take care everything for people
From
To
Reason for Leaving
N/A
May we contact this employer?  Yes

Company Name
JDA in home Quality Care LLC
Phone
6307797447
Address

1007 whittington dr, Geneva il

Supervisor
Annabelle
Job Title
Caregiver
Salary or Rate of Pay
14.5-18
Responsibilities
Take care everything for people
From
To
Reason for Leaving
N/A
May we contact this employer?  Yes

Company Name
Open arms
Phone
8472724997
Address

900 Skokie blv
212,Northbrook il

Supervisor
Dova
Job Title
Caregiver
Salary or Rate of Pay
14.5-18
Responsibilities
Take care everything for people
From
To
Reason for Leaving
Still working with agency
May we contact this employer?  Yes

Company Name
Halina home agency
Phone
6306700819
Address

555 Marion ave,St Charles il

Supervisor
Dan
Job Title
Caregiver
Salary or Rate of Pay
14.5-18
Responsibilities
Take care everything for people
From
To
Reason for Leaving
Still working with agency
May we contact this employer?  Yes

Company Name
Halina's home agency
Phone
6306700819
Address

555 marion ave, st Charles il

Supervisor
Dan
Job Title
Caregiver
Salary or Rate of Pay
14.5-18
Responsibilities
Taking care everything for people
From
To
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.
Care giver
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
Dane
Phone
8477588476
Address
1201 s dunton ave,Arlington heights il
Relationship
Client husband

Name
Donica
Phone
7733695921
Address
In chicago il
Relationship
Client daughter

Name
Jane
Phone
8473826670
Address
In Elgin il
Relationship
Client daughter
Additional Information
Feel free to add any notes or additional information to your application in the space provided below.

Yes

Thank you for entering your employment history. If gaps exist in your employment history, please explain the gaps here.
Care giver
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
Oyun Siciliano

PART FIVE – APPLICATION SUBMISSION

Application Status
Draft
Date Submitted