Caregiver Job Application


APPLICANT INFORMATION

Application Status
Draft
Name (First, Middle, Last)
Kentest Testing6 Smith
Created: 10/19/2020
Other names under which employment may be verified:  Kent Smith
Updated: October 20, 2020

Home Address
Street Address
123 Main
Unit/Suite Number
Apt 2B
City ST/Zip
Chicago, IL 60606
Home Phone
312-555-1212
Mobile Phone
312-555-1414
Alternate Phone
312-555-5678

Have you ever worked for us before?   No
If no, how did you hear about us? website
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
No
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.  Acme Caregivers of America

How many years have you worked as a professional caregiver?  4
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.

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

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Availability

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

Education

High School   High School Name Here
Location:   Chicago, IL
Did you graduate?   Yes
Subjects Studied   General Studies

College   College Name Here
Location:   Chicago, IL
Did you graduate?   No
Degree:   Biology

Other:   
Location:   
Did you graduate?   
Degree:   

Special awards you earned or courses you have taken.
Perfect attendance

Military Service

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

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
AAA Inc
Phone
8475551212
Address

987 1st St
Big City, IL 60606

Supervisor
Coach Ditka
Job Title
Caregiver
Salary or Rate of Pay
$20
Responsibilities
take care of client
From
09/07/2020
To
10/14/2020
Reason for Leaving
moved
May we contact this employer?  Yes

Company Name
Acme Brick Source
Phone
312-555-1212
Address

123 Main
Chicago IL 60606

Supervisor
John Doe
Job Title
Clerk
Salary or Rate of Pay
$20
Responsibilities
processed paperwork
From
10/03/2019
To
10/14/2020
Reason for Leaving
More money
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
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
Mike Ditka
Phone
312-555-1212
Address
123 S. Main, Chicago
Relationship
friend

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.

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Thank you for entering your employment history. If gaps exist in your employment history, please explain the gaps here.
No gaps
Additional Certifications
No additional certifications or licenses provided.

Have any of your certifications or licenses been suspended or revoked?  
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
Kentest Smith

PART FIVE – APPLICATION SUBMISSION

Application Status
Draft
Date Submitted