Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Linda Diana Taylor
Created: 09/18/2019
Other names under which employment may be verified:  Linda Favors Taylor;
Updated: September 18, 2019

Home Address
Street Address
7447 South Shore Drive
Unit/Suite Number
Apt. 8 C
City ST/Zip
Chicago, IL 60649
Home Phone
Mobile Phone
773-749-1332
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us? Friend
Rate of pay desired.   $30.00/hr
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
No
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.  Dawson City College

How many years have you worked as a professional caregiver?  20
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.

Will provide excellent nursing care to the best of my ability.

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

Was once a first responder for a client who committed suicide.

Availability

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

Education

High School   Forrestville-King
Location:   Chicago, IL
Did you graduate?   Yes
Subjects Studied   General Studies

College   Dawson City College
Location:   Chicago, IL
Did you graduate?   Yes
Degree:   LPN

Other:   MSTA Business College
Location:   Chicago, IL
Did you graduate?    Yes
Degree:   Medical Transcription

Special awards you earned or courses you have taken.
Current CPR and CPI cards

Military Service

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

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
All Faith Pavilion
Phone
3123262000
Address

3500 South Giles
Chicago, IL

Supervisor
Ms. Mukes, RN
Job Title
LPN
Salary or Rate of Pay
24.00/hr
Responsibilities
charge nurse
From
08/03/2015
To
08/31/2018
Reason for Leaving
Facility closed
May we contact this employer?  No

Company Name
Clayton Residential
Phone
Address

2026 North Clark
Chicago, IL

Supervisor
Christopher Becker DON
Job Title
LPN
Salary or Rate of Pay
27.00/hr
Responsibilities
Charge nurse
From
09/08/2018
To
09/18/2019
Reason for Leaving
N/A -- Still employed
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.
Took 1 year off (2014) to care for ill family member.
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
Carol Drake
Phone
4783026349
Address
Warner Robins, GA
Relationship
Friend

Name
Bernadette Casserly
Phone
312-751-2342
Address
845 Michigan Ave.
Relationship
Friend

Name
Julianna Nelson
Phone
312-351-0637
Address
Chicago, IL
Relationship
Friend
Additional Information
Feel free to add any notes or additional information to your application in the space provided below.

Prefer Private Duty Cases.

Thank you for entering your employment history. If gaps exist in your employment history, please explain the gaps here.
Took 1 year off (2014) to care for ill family member.
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
Linda D. Favors Taylor

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
September 18, 2019
This application has been submitted and can no longer be edited.