Caregiver Job Application


APPLICANT INFORMATION

Application Status
Draft
Name (First, Middle, Last)
Alfredo Arevalo
Created: 08/07/2019
Other names under which employment may be verified:  Al
Updated: August 12, 2019

Home Address
Street Address
2828 N Sawyer ave.
Unit/Suite Number
apt 203
City ST/Zip
chicago, IL 60618
Home Phone
Mobile Phone
7732551232
Alternate Phone
Email Address

Have you ever worked for us before?   No
If no, how did you hear about us? Friend
Rate of pay desired.   $20-25
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:
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.  Traycee

How many years have you worked as a professional caregiver?  14
What percent of your previous case work has been for an agency?  1
Please explain how you will contribute to strengthen the Water Tower Nursing team.

Sharing experiences from my past client.

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

I had a client with PD that came out of the hospital and a bedridden patient with G tube.....! In 3 months time caring for him i made him gained his strenght back and up on his feet. Family didnt ecpected that he will survived....client lived for another 7 years under my care.

Availability

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

Education

High School   
Location:   
Did you graduate?   No
Subjects Studied   

College   Univ of the East
Location:   Philippines
Did you graduate?   Yes
Degree:   BSCE

Other:   CNA
Location:   Texas
Did you graduate?   
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
Seymour A Cohen c/o Liza Cohen
Phone
17738520845
Address

910 N lakeshore dr, chicago, il 60601

Supervisor
Job Title
Night shift Caregiver
Salary or Rate of Pay
$ 19
Responsibilities
Provide assistance and need throughout the night
From
04/12/2015
To
03/01/2019
Reason for Leaving
deceased
May we contact this employer?  Yes

Company Name
David and Shirley Ferguson c/o Julie Decker
Phone
17734907812
Address

2960 N lakeshore dr., Chicago, Il 60657

Supervisor
Job Title
Caregiver/helper
Salary or Rate of Pay
$20/hr
Responsibilities
help and assist on daily living needs
From
05/12/2015
To
01/01/2018
Reason for Leaving
worked part time only
May we contact this employer?  Yes

Company Name
Francis Donovan c/o Patricia Hunt
Phone
16303080880
Address

318 forest ave., Oak Park, Il 60302

Supervisor
Job Title
live-in Caregiver
Salary or Rate of Pay
Responsibilities
From
02/12/2007
To
08/12/2014
Reason for Leaving
deceased
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.
Vacation and job/client prospecting
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
todd Hunt
Phone
16364894457
Address
Relationship
friend

Name
Celia Manalus
Phone
17737507595
Address
Relationship
friend

Name
Janet Vallejos
Phone
17738183104
Address
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.
Vacation and job/client prospecting
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
Alfredo Arevalo

PART FIVE – APPLICATION SUBMISSION

Application Status
Draft
Date Submitted