Caregiver Job Application


APPLICANT INFORMATION

Application Status
Draft
Name (First, Middle, Last)
Lisa Avelar
Created: 07/31/2019
Other names under which employment may be verified:  None
Updated: November 26, 2019

Home Address
Street Address
4732 s Ada st
Unit/Suite Number
City ST/Zip
Chicago , IL 60609
Home Phone
Mobile Phone
773-940-5003
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us? Online
Rate of pay desired.   13.00
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
No
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.  At Home rights

How many years have you worked as a professional caregiver?  2
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.

I compare meals I always clean their home if is needed ,love of them talk to them listen to their stories.

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   Somewhat
Location:   Chicago
Did you graduate?   No
Subjects Studied   Basic

College   
Location:   
Did you graduate?   No
Degree:   

Other:   
Location:   
Did you graduate?    No
Degree:   

Special awards you earned or courses you have taken.
None

Military Service

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

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
Division of Hehabilitation Services
Phone
312-338-6600
Address

6221 s Emerald Dr.
Chicago,Il 60621

Supervisor
Job Title
Personal Care Assistant
Salary or Rate of Pay
13.00
Responsibilities
Repair his meals make sure you take his meds
From
08/03/2015
To
09/26/2016
Reason for Leaving
client didn’t need me no more
May we contact this employer?  Yes

Company Name
Right at Home
Phone
773-775-4677
Address

8424 s Skokie Blvd,
Skokie, Ik 60077

Supervisor
Heather Lantry
Job Title
General Manager ower
Salary or Rate of Pay
13.00
Responsibilities
I cleaned clients home, bath them, Pier their meals change your cabaret change their pampers ,did the laundry
From
06/12/2019
To
10/01/2019
Reason for Leaving
I was lookin for other Job.
May we contact this employer?  Yes

Company Name
Senior Helpers
Phone
312-867-7110
Address

1165 N Clark st Chicago,Ik 60610

Supervisor
Musa Bathusi
Job Title
Supervisor
Salary or Rate of Pay
12.00
Responsibilities
Repairing meals keep them company And cleaning their homes
From
01/21/2019
To
04/25/2019
Reason for Leaving
No show, no call
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.
Provide patient with helping moving in and out of bed , flooring housekeeping duties such as cooking cleaning washing clothes and dishes , Maintained records of patients daily medication ensuring patient taking medication
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
Yolanda Resendiz
Phone
773 827 4994
Address
3808 Tennessee Gary Indiana 46409
Relationship
Friend

Name
Cindy Cabral
Phone
7739935502
Address
4832 s Justine st Chicago Ik 60609
Relationship
Friend

Name
Phone
Address
Relationship
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.
Provide patient with helping moving in and out of bed , flooring housekeeping duties such as cooking cleaning washing clothes and dishes , Maintained records of patients daily medication ensuring patient taking medication
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)
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
Lisa Avelar

PART FIVE – APPLICATION SUBMISSION

Application Status
Draft
Date Submitted