Caregiver Job Application


APPLICANT INFORMATION

Application Status
Draft
Name (First, Middle, Last)
Marsheen Dervin
Created: 11/19/2020
Other names under which employment may be verified:  Franchetta Dervin
Updated: November 26, 2020

Home Address
Street Address
2601 S Prairie
Unit/Suite Number
Apt 302
City ST/Zip
Chicago, IL 60616
Home Phone
7736193415
Mobile Phone
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us? Doreen Anderson
Rate of pay desired.   $20 p/h
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
No
Dogs
No
Smoker
No
What languages do you speak?   english
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  Gareda LLC, Brightstar, Novastaff

How many years have you worked as a professional caregiver?  6
What percent of your previous case work has been for an agency?  20
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?   No

Education

High School   Chicago Vocational HS
Location:   Chicago,IL
Did you graduate?   Yes
Subjects Studied   General ED

College   Olive Harvey
Location:   Chicago,Il
Did you graduate?   No
Degree:   

Other:   ATS Institutes of Technology
Location:   Chgo,IL
Did you graduate?    Yes
Degree:   Nursing

Special awards you earned or courses you have taken.
Maternity, Peds, Psych, Pharmacology,Med Surg

Military Service

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

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
Lexington Healthcare
Phone
7798757860
Address

14620 John Humphrey Road
Orland Park, Il 60426

Supervisor
Tanya Martin
Job Title
CNA
Salary or Rate of Pay
$18
Responsibilities
Perform ADLs, Respond to call lights, Monitor residents Vital signs,feed and monitor residents
From
10/26/2015
To
12/26/2018
Reason for Leaving
Attending Nursing School
May we contact this employer?  Yes

Company Name
Novastaff Healthcare
Phone
6304721122
Address

2021 Midwest Rd #200
Oakbrook,IL. 60523

Supervisor
n/a
Job Title
CNA
Salary or Rate of Pay
$18 p/h
Responsibilities
Perform ADLs, Engage in activities with residents, Increase confidence and encourage independence
From
11/26/2019
To
03/26/2020
Reason for Leaving
Preparing for Nclex
May we contact this employer?  No

Company Name
Gareda LLC
Phone
708 8681300
Address

1400 Huntington Drive
Calumet City, Il

Supervisor
Donna Bowen
Job Title
Home Care Aide
Salary or Rate of Pay
$14.50
Responsibilities
Cooking, cleaning, washing clothes,
From
07/26/2019
To
Reason for Leaving
Present
May we contact this employer?  No

 

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 had to devote more time to my Nursing Classes.
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
Alisa Lewis
Phone
7085747087
Address
14428 S Normal
Relationship
Friend

Name
Joyce Marsh
Phone
7734052347
Address
8019 S Indiana
Relationship
Friend

Name
Tracy Samuda
Phone
3123162527
Address
10036 S Rhodes Ave
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.
I had to devote more time to my Nursing Classes.
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)
No

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
Marsheen Dervin

PART FIVE – APPLICATION SUBMISSION

Application Status
Draft
Date Submitted