Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Merrill St. Marie Perkins
Created: 10/05/2019
Other names under which employment may be verified:  
Updated: October 16, 2019

Home Address
Street Address
12552 S Paulina St
Unit/Suite Number
City ST/Zip
Calumet Park , IL 60827
Home Phone
Mobile Phone
708 845 7380
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us? I had a private client at the water tower residents and your agency was recommended to me
Rate of pay desired.   $20 open to discussion
Do you have a valid driver’s license?   Yes
Do you have access to a car? Yes

I am able to work client who has or lives with:
Family
Yes
Hospice
No
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.  Marsol Enterprise INC Home Care and Nursing Agency

How many years have you worked as a professional caregiver?  15
What percent of your previous case work has been for an agency?  7
Please explain how you will contribute to strengthen the Water Tower Nursing team.

I have over 20 plus years in management and I’ve been the care coordinator for 8 yrs in private care at the water tower residents and my client was totally disabled

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

I was the liaison for the client POA Doctor Nursing staff Pharmacy and all her business affairs I did all the hiring and training of the staff Most important I coordinated her care that was tailored to her needs

Availability

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

Education

High School   Percy Julian
Location:   Chicago IL
Did you graduate?   Yes
Subjects Studied   English Business

College   University of Illinois
Location:   Champagne-Urbana
Did you graduate?   No
Degree:   

Other:   Olive Harvey
Location:   Chicago IL
Did you graduate?    No
Degree:   

Special awards you earned or courses you have taken.
Best in Sales Most Improved Location and Eucharist Minister and Lector

Military Service

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

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
I care for Seniors
Phone
708 674 3187
Address

180 E Pearson Apt 5702

Supervisor
Frances Schwartz
Job Title
Supervising Healthcare Coordinator/Companion
Salary or Rate of Pay
$35
Responsibilities
Manager and overseeing of everything and everyone
From
09/03/2012
To
08/16/2019
Reason for Leaving
My lady moved to a nursing home in Washington DC
May we contact this employer?  Yes

Company Name
Marsol Enterprises INC
Phone
708 833 7375
Address

20180 Governors Highway suite 206 Olympia Fields IL 60461

Supervisor
Funke Oriaikhi
Job Title
Supervising Home Maker
Salary or Rate of Pay
22.50
Responsibilities
Overseeing home care workers and following up with clients doing site visits
From
01/03/2005
To
04/30/2012
Reason for Leaving
Business downsized
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 employment has always been in management or self employed my Resume will reflect that which I will provide
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
Dr.Robert Kaplan
Phone
773 774 7300
Address
American Disabled 5962 N Alston Ave 60646
Relationship
Business relationships (clients doctor)

Name
Amy Gumiran
Phone
312 343 7062
Address
HRS Nursing and Rehab 1806 S Highland Ave Lombard IL 60148
Relationship
RN (I worked closely with on behalf of my client)

Name
Father Casimir
Phone
773 860 4318
Address
St Stanislaus Church 14414 McKinley Ave Posen IL 60469
Relationship
Priest
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 employment has always been in management or self employed my Resume will reflect that which I will provide
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)
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
Merrill Perkins

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
October 6, 2019
This application has been submitted and can no longer be edited.