Caregiver Job Application


APPLICANT INFORMATION

Application Status
Draft
Name (First, Middle, Last)
Belinda M Moton
Created: 06/25/2019
Other names under which employment may be verified:  
Updated: October 15, 2020

Home Address
Street Address
11660 s vincennes ave
Unit/Suite Number
City ST/Zip
Chicago, IL 60643
Home Phone
2244770240
Mobile Phone
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us?
Rate of pay desired.   13
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
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?  8
What percent of your previous case work has been for an agency?  7
Please explain how you will contribute to strengthen the Water Tower Nursing team.

Call in

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

I work with Alzheimer's and Dementia

Availability

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

Education

High School   Northeast High School
Location:   Clarksville Tennessee
Did you graduate?   Yes
Subjects Studied   Math

College   
Location:   
Did you graduate?   
Degree:   

Other:   
Location:   
Did you graduate?   
Degree:   

Special awards you earned or courses you have taken.
Cpr

Military Service

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

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
Livhome
Phone
1847 470 1703
Address

5215 old orchard rd suite 260 skokie ill 60078

Supervisor
Loddi
Job Title
Caregiver
Salary or Rate of Pay
12.25
Responsibilities
Taking care of clients
From
11/07/2017
To
12/07/2019
Reason for Leaving
Still going here
May we contact this employer?  Yes

Company Name
Home life healthcare
Phone
847 413 1611
Address

1020 golf rd hoffman estate il 60169

Supervisor
Who ever answer the phone
Job Title
Caregiver
Salary or Rate of Pay
12
Responsibilities
Taken care of the client
From
06/28/2014
To
05/10/2017
Reason for Leaving
No clients
May we contact this employer?  Yes

Company Name
Home instead senior care
Phone
847 413 3300
Address

3100 dundee rd 107 northbrook il 60062

Supervisor
Who ever answer
Job Title
Caregiver
Salary or Rate of Pay
12.00
Responsibilities
Taking care of clients
From
08/05/2015
To
08/03/2017
Reason for Leaving
No clients
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.
NA
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
Juliane smith
Phone
312 3513556
Address
2110 hebren zion il 60099
Relationship
Friend

Name
Marie s
Phone
312 686 5759
Address
12210 ada chicago il 60643
Relationship
Friend

Name
Lele wells
Phone
262 771 9022
Address
310 s lake st 406 Waukegan il 60085
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.
NA
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
Belinda marge moton

PART FIVE – APPLICATION SUBMISSION

Application Status
Draft
Date Submitted