Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Rhoda Edna Jones
Created: 09/24/2019
Other names under which employment may be verified:  
Updated: September 30, 2019

Home Address
Street Address
15324 Chicago road
Unit/Suite Number
City ST/Zip
Dolton, IL 60419
Home Phone
Mobile Phone
708-639-8322
Alternate Phone
Email Address

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
No
What languages do you speak?   english
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  Humana At Home

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 think I’ll be a good candidate to work with because I have been in the nursing field for 16 years I am a c.n.a and I’ve been doing HomeCare for 2 years and half . I’m reliable and caring person I love taking care of people that’s my passion

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

I knew I wanted to be a c.n.a back in 2002 my mom was in bad car accident where she broke her leg and she had to learn how to walk again I was 6 months pregnant and I helped my mom and that’s when I decided I wanted to go to school and I did.... and I also took care of my dad when he was diagnose with CHF went to every dr appointment with him.... I have passion for taking care of people.

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   Fenger
Location:   Chicago il
Did you graduate?   Yes
Subjects Studied   General security

College   
Location:   
Did you graduate?   
Degree:   

Other:   
Location:   
Did you graduate?   
Degree:   

Special awards you earned or courses you have taken.
Security and food sanitation license

Military Service

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

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
Humana At Home
Phone
312 329 9060
Address

550 w Adams

Supervisor
Pat Graff
Job Title
Caregiver
Salary or Rate of Pay
$13.25
Responsibilities
Providing quality care and assisting patient with daily activities such as grooming preparation with meals and etc.
From
03/20/2017
To
09/24/2019
Reason for Leaving
Still working here
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
Beverly Pittman
Phone
708 515 8940
Address
Relationship
Best friend

Name
Keisha Taylor
Phone
773 216-5439
Address
Relationship
Friend

Name
Pearl Battle
Phone
708 631-8373
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.
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)
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
Rhoda Jones

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
September 24, 2019
This application has been submitted and can no longer be edited.