Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Sylvia A Broadway
Created: 08/08/2019
Other names under which employment may be verified:  
Updated: August 8, 2019

Home Address
Street Address
4850 s lake park ave #2307
Unit/Suite Number
City ST/Zip
Chicago , IL 60615
Home Phone
7738759966
Mobile Phone
Alternate Phone
Email Address

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

How many years have you worked as a professional caregiver?  0
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.

I will assist in daily needs non medical for my client.

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

I have provided assistance to several elderly family members & friends for the pass 5yrs. My mother suffered a stroke & I became her caregiver assisting in house chores, cooking , reminding her to take prescription medication. Assisting in bathing & dressing.

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   HydePark C.A
Location:   Chicago Illinois
Did you graduate?   Yes
Subjects Studied   

College   Harold Washington City college
Location:   Chicago Illinois
Did you graduate?   Yes
Degree:   Associate

Other:   Chicago Police Academy
Location:   Chicago Illinois
Did you graduate?    Yes
Degree:   State of Illinois certified policemen

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
Chicago Police Dept
Phone
3127475000
Address

3510 s. Michigan

Supervisor
Hr
Job Title
Police officer
Salary or Rate of Pay
50k
Responsibilities
Serving & protecting the citizens of Chicago
From
05/31/2019
To
09/15/2019
Reason for Leaving
Retired
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.
N/A
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
Joyce Anderson
Phone
7732853071
Address
4850 s lake park ave
Relationship
Friend

Name
Carol
Phone
7736450531
Address
4724 s Greenwood
Relationship
Friend

Name
Yolanda Carter
Phone
7733269967
Address
1645 e 57th
Relationship
Friend
Additional Information
Feel free to add any notes or additional information to your application in the space provided below.

I’m a retired Chicago Police officer. I would love to continue to serve the citizens of Chicago. I have excellent people skills. I will ensure clients have the best assistance & care as a non medical companion.

Thank you for entering your employment history. If gaps exist in your employment history, please explain the gaps here.
N/A
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
Sylvia A. Broadway

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
August 8, 2019
This application has been submitted and can no longer be edited.