Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
christine adams
Created: 07/06/2019
Other names under which employment may be verified:  
Updated: March 17, 2020

Home Address
Street Address
4842 N drake ave
Unit/Suite Number
City ST/Zip
Chicago, IL 60625
Home Phone
7733833537
Mobile Phone
312-358-3770
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us? Client
Rate of pay desired.  
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
Yes
Smoker
Yes
What languages do you speak?   english, tagalog
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  Home for Good Senior Care

How many years have you worked as a professional caregiver?  10
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   Yes
Weekdays   Yes
Weekends   Yes
Live-in   No
Can you travel outside the city of Chicago to work?   No

Education

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

College   University of Mindanao
Location:   Philippines
Did you graduate?   Yes
Degree:   

Other:   CNA
Location:   
Did you graduate?    Yes
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
Home for Good Senior Care
Phone
773-572-4875
Address

6246 N Pulaski Rd, Chicago, Illinois, 60646

Supervisor
Cecille Pimentel
Job Title
Caregiver/ C.N.A
Salary or Rate of Pay
Responsibilities
Patient Care
From
08/09/2009
To
03/17/2020
Reason for Leaving
Part-time, 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.
No gaps or no explanation provided.
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
Arlynn Krauss
Phone
312-330-0566
Address
Downtown Chicago
Relationship
Client

Name
Karen Sales
Phone
309-585-8383
Address
Relationship
Coworker

Name
Marie Epil
Phone
773-717-9496
Address
Relationship
Coworker
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.
No gaps or no explanation provided.
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
Christine Tayo Adams

PART FIVE – APPLICATION SUBMISSION

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