Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Stacie D Smith
Created: 09/16/2019
Other names under which employment may be verified:  
Updated: October 21, 2019

Home Address
Street Address
12552 S. Ashland
Unit/Suite Number
City ST/Zip
Calumet park, IL 60827
Home Phone
Mobile Phone
3127096401
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us?
Rate of pay desired.   13
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?  Yes
If yes, explain.  Addus healthcare

How many years have you worked as a professional caregiver?  8
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’m a very patient person which is good with dealing with clients. Who have Alzheimer’s , Dementia Etc.
I’m very dedicated to doing my daily tasks and I get my job even under pressure. I’m a team player, that’s no I in team. Last I’m very respectful and professional while I’m on the clock.

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

I had a lot of personal moments with my clients through the years. One in particular I remember was my client reminiscing On her days as working for the post office. My client was so happy telling me the stories , she began to cry. All she wanted was someone to keep her company and listen to her.

Availability

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

Education

High School   Jefferson
Location:   Chicago,iL 60612
Did you graduate?   Yes
Subjects Studied   Business

College   Moraine valley community college
Location:   Blue island, iL 60406
Did you graduate?   No
Degree:   Business

Other:   
Location:   
Did you graduate?   
Degree:   

Special awards you earned or courses you have taken.
High school diploma,

Military Service

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

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
Addus healthcare
Phone
7733965600
Address

2335 95th st Chicago iL, 60643

Supervisor
Eboney Glen
Job Title
Homecare aid
Salary or Rate of Pay
13.00
Responsibilities
Assisting clients in and out of their beds. Cooking the client meals , also meal preparation. Washing the clients clothing. Medication reminders, lady sticking to the client care plan.
From
10/03/2012
To
09/30/2019
Reason for Leaving
I’m currently still with my company
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.
My only gaps I had between is I went to college.
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
Esther Parkman
Phone
7739391407
Address
12104 s green Chicago il 60612
Relationship
College associate

Name
Damon Brown
Phone
7088024874
Address
16401 California markham,il 60643
Relationship
Mentor

Name
Jasmine Clay
Phone
7085399655
Address
12701 May calumet park,iL 60827
Relationship
College associate
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.
My only gaps I had between is I went to college.
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)
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
Stacie D Smith

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
October 21, 2019
This application has been submitted and can no longer be edited.