Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
darryl o temkin
Created: 08/17/2020
Other names under which employment may be verified:  
Updated: August 17, 2020

Home Address
Street Address
3022 LEXINGTON LN
Unit/Suite Number
City ST/Zip
HIGHLAND PARK, IL 60035
Home Phone
8474332109
Mobile Phone
8478197297
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us? via Mark Paley
Rate of pay desired.   competitive
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
No
Cats
No
Dogs
No
Smoker
No
What languages do you speak?   english
Do you have any caregiver training from other home services agencies?  No
If yes, explain.  

How many years have you worked as a professional caregiver?  0
What percent of your previous case work has been for an agency?  0
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.

Availability

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

Education

High School   South Shore
Location:   Chicago
Did you graduate?   Yes
Subjects Studied   college prep

College   University of Illinois Pharmacy School
Location:   chicago, illinois
Did you graduate?   Yes
Degree:   B.S. Pharmacy

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
North Shore University Healthcare System
Phone
Address

1157 Church Street, Northbrook in Sunset Foods

Supervisor
Tina
Job Title
Staff Pharmacist
Salary or Rate of Pay
$66 per hour
Responsibilities
Filled prescriptions, counseled patients, ordered drugs
From
10/31/2005
To
09/17/2014
Reason for Leaving
May we contact this employer?  Yes

Company Name
Sinai Community Pharmacy
Phone
773-257-6900
Address

15th and California, Chicago, IL

Supervisor
Tom Yu
Job Title
Pharmacist in charge
Salary or Rate of Pay
$55
Responsibilities
Managed pharmacy and staff, ordered drugs, interacted with patients
From
05/01/2015
To
04/01/2020
Reason for Leaving
retired
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.
see resume attached for complete career path
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
Michael Weisman
Phone
Address
Relationship
co-partner at Solomon Cooper Drugs

Name
Mark Paley
Phone
Address
Relationship
co-worker at Solomon Cooper Drugs

Name
Alan Maslov
Phone
Address
Relationship
co worker at NSUHS
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.
see resume attached for complete career path
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)
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
Darryl Temkin

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
August 17, 2020
This application has been submitted and can no longer be edited.