Caregiver Job Application


Application Status
Name (First, Middle, Last)
Sharon Hemphill
Created: 07/16/2019
Other names under which employment may be verified:  N/A
Updated: July 16, 2019

Home Address
Street Address
3538 1/2 S. King drive
Unit/Suite Number
Unit - S3
City ST/Zip
Chicago, IL 60653
Home Phone
Mobile Phone
Alternate Phone
Email Address

Have you ever worked for us before?   No
If no, how did you hear about us? Google
Rate of pay desired.   15.00 hrly
Do you have a valid driver’s license?   Yes
Do you have access to a car? No

I am able to work client who has or lives with:
What languages do you speak?   english
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  Eden, Breakers, Continental Nursing

How many years have you worked as a professional caregiver?  5
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.

My experience & service in caring for the love ones of families with dementia, diabetes, alzheimers & cancer patients has equipped me as a collaborator who has a passion for helping others in a myriad of settings. I'm certain I would prove to be a keen asset to your company.

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

I cared for a senior with dementia who had recently been taking out of her home and moved in with a relative. She insisted that there was a unit identical to the unit we were in above, but we were already located on the highest level. She was trying to locate a door that lead to the stairwell to get to it. This happened every day. I took out photo albums and ask her to identify the family members, then I went to the pictures that hung on walls....that focused her attention away from the looking for the stairwell....?


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


High School   South Shore High School
Location:   Chicago, IL
Did you graduate?   Yes
Subjects Studied   

College   Sawyer Secretarial College
Location:   Chicago IL
Did you graduate?   Yes
Degree:   AS

Other:   Northwestern Institute of health and Technology
Location:   Chicago IL
Did you graduate?    Yes
Degree:   Patient care Technician

Special awards you earned or courses you have taken.
Customer Service Certified, CNA, EKG, & Phlebotomy

Military Service

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

Licenses and Certifications


Company Name
Manpower Staffing

100 Manpower Pl.
Milwaukee, Wisconsin

Job Title
Office Administrator
Salary or Rate of Pay
22.50 hrly
Provide highly effective and organized Administrative support to Branch Manager and Sales team of Otis Elevator Company as first point of contact. Utilize a wide range of administrative functions that require advanced problem solving skills under minimal direction, while performing as a team player. Handle sensitive information and maintain perspective under pressure. Keep office running smoothly and equipment functional. Create and update logs and directories. Prepare all invoices for processing & payment. Responsible for the ordering of all office supplies, coffee, etc. Receive, sort & distribute mail/packages from couriers. Handle special projects. Cater meals for meetings, etc. Process and keep track of Inspection Permits. Drafts permit checks for payment to City of Chicago Department of Buildings; Created electronic filing system to track payments. Notarize and assist with preparation of legal documents, and rotate to various office duties as needed.
Reason for Leaving
Contract position
May we contact this employer?  Yes



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.
Karen McIntosh

Mary Grimler

Camille Boyce
Additional Information
Feel free to add any notes or additional information to your application in the space provided below.

I have an updated resume I can provide that focuses on Administrative skills, and not caregiving. I will provide if requested. Respectfully

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)
If hired, would you be able to provide a copy of your Social Security Card?* (IDPH requirement)

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
Sharon L. Hemphill


Application Status
Date Submitted
July 16, 2019
This application has been submitted and can no longer be edited.