Caregiver Job Application


APPLICANT INFORMATION

Application Status
Draft
Name (First, Middle, Last)
Nellie Q Francis
Created: 08/26/2019
Other names under which employment may be verified:  
Updated: August 26, 2019

Home Address
Street Address
708 N Lockwood Ave
Unit/Suite Number
City ST/Zip
Chicago, IL 60644
Home Phone
Mobile Phone
2624178626
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us?
Rate of pay desired.   14.00
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
Yes
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?  2
What percent of your previous case work has been for an agency?  100
Please explain how you will contribute to strengthen the Water Tower Nursing team.

I will contribute by showing how much of a hard working caregiverI am. I will show how dedicated I am to my job and my client and how important my clients are to me I will show how responsible and respectful I am to my client I will make sure my client is getting all proper care and make sure my client feels very comfortable around me I will make sure my client knows that I am here to help and make he or she feel very welcomed and safe and they will be getting everything they need done while in my care I will follow all rules thats given and ask questions if I'm not aware because I want to make sure I get everything done and do everything correctly I will be a great caregiver for the water tower nursing team.

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

I worked as a caregiver at a group home called roots residential where my duties consisted of monitoring residents. I assisted with personal and hygiene care ,food preparation, home maintenance, housekeeping, mobility transportation, bed transfer and also assisting with gait belt and hoyer lifting and also attending doctors appointments and outing with my clients.

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   Orr Academy High School
Location:   Chicago,IL
Did you graduate?   Yes
Subjects Studied   general studies

College   
Location:   
Did you graduate?   
Degree:   

Other:   
Location:   
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
Phone
Address
Supervisor
Job Title
Salary or Rate of Pay
Responsibilities
From
To
Reason for Leaving
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
Phone
Address
Relationship

Name
Phone
Address
Relationship

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.
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?  
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)

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
Disclaimer has not been accepted. Job Application will not be processed until the Disclaimer is accepted.

PART FIVE – APPLICATION SUBMISSION

Application Status
Draft
Date Submitted