Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Flordelis Gallanosa Fordelon
Created: 05/28/2019
Other names under which employment may be verified:  
Updated: June 28, 2019

Home Address
Street Address
4428 N Central Ave
Unit/Suite Number
Apt 1E
City ST/Zip
Chicago , IL 60630
Home Phone
Mobile Phone
407-729-0404
Alternate Phone
Email Address

Have you ever worked for us before?   No
If no, how did you hear about us? My sister works with you
Rate of pay desired.   175
Do you have a valid driver’s license?   No
Do you have access to a car? No

I am able to work client who has or lives with:
Family
Yes
Hospice
Yes
Cats
Yes
Dogs
No
Smoker
No
What languages do you speak?   english, tagalog
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  Custom Home Care

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

I was a professional nurse in the Philippines for more then 20 years. I also worked as a registered nurse in Saudi Arabia for 3 years. I worked in an assisted facility in Florida as a supervisor, medication technician, recorder, meal preparer and caregiver for 9 years. I think these knowledge and work experience are enough for me to be able to help in strengthening the team.

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

I worked with a client with dementia and I was patient enough to understand her mood swings by diverting her attention from something that triggers her through several techniques such as asking questions about her family; showing some old pictures; daily exercises, singing and other functional activities.

Availability

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

Education

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

College   Philippines
Location:   Naga
Did you graduate?   Yes
Degree:   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
Loving Heart Home
Phone
407-922-2630
Address

509 Verona St
Kissimmee,FL
34741

Supervisor
Edith Andrada
Job Title
Owner
Salary or Rate of Pay
3,000 monthly
Responsibilities
Supervisor, meds technician, charting and recording
From
10/02/2004
To
10/01/2014
Reason for Leaving
Moved to Ocala, FL
May we contact this employer?  Yes

Company Name
Custom Home Care
Phone
773-561-4663
Address

2716 W Peterson
Chicago, ILLINOIS

Supervisor
Grace
Job Title
Caregiver
Salary or Rate of Pay
156 a day
Responsibilities
Medication reminder, ADL, meal prep, housekeeping
From
01/08/2018
To
08/31/2018
Reason for Leaving
Vacation in Philippines
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 went to the Philippines and moved to other states.
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
Edith Andrada
Phone
407-922-2630
Address
509 Verona St Kissimmee,FL
Relationship
Employer

Name
Lucy Madamba
Phone
407-401-6036
Address
Orlando, FL
Relationship
Co worker

Name
Clemence
Phone
773-668-2543
Address
Chicago, IL
Relationship
co worker
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 went to the Philippines and moved to other states.
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
Flordelis Fordelon

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
May 28, 2019
This application has been submitted and can no longer be edited.