Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Militza Garcia
Created: 10/12/2019
Other names under which employment may be verified:  
Updated: October 12, 2019

Home Address
Street Address
3049 Scott St.
Unit/Suite Number
City ST/Zip
Franklin Park, IL 60131
Home Phone
Mobile Phone
2247627509
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us?
Rate of pay desired.   17
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
Yes
Cats
Yes
Dogs
Yes
Smoker
Yes
What languages do you speak?   english, spanish
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  Lifestyle options

How many years have you worked as a professional caregiver?  2
What percent of your previous case work has been for an agency?  50
Please explain how you will contribute to strengthen the Water Tower Nursing team.

Give clients good quality of life. Meet clients needs. My strong work ethic to care for the clients. Knowledgeable skills and personal care.

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

Some of my experiences as a caregiver have been caring for clients dementia, Alzheimer’s, clients who have had strokes, clients who are ill and clients who just need a companion.

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   East leyden
Location:   Illinois
Did you graduate?   Yes
Subjects Studied   

College   Triton
Location:   Illinois
Did you graduate?   No
Degree:   

Other:   
Location:   Illinois
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
Lifestyle options inc
Phone
(847) 240-7330
Address

1250 Village Dr, Arlington Heights, IL 60004

Supervisor
Christina Delmundo
Job Title
Caregiver/Community Care Coordinator
Salary or Rate of Pay
It varies
Responsibilities
Clients personal care, laundry, housekeeping, drive them to a destination, billing, care calls
From
03/16/2019
To
10/12/2019
Reason for Leaving
Currently still working there
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.
Before lifestyle options I was my mother’s caregiver. She was battling with cancer for 9 months. I did bed baths, doctors appointment, changed her colostomy bag, feed, personal care.
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
Christina Delmundo
Phone
(773) 387-0462
Address
N/A
Relationship
Supervisor

Name
Estella
Phone
(847) 757-5237
Address
N/A
Relationship
Co-Worker

Name
Roseline
Phone
(224) 578-0128
Address
N/A
Relationship
Co-Worker
Additional Information
Feel free to add any notes or additional information to your application in the space provided below.

I’m currently in a CNA program.

Thank you for entering your employment history. If gaps exist in your employment history, please explain the gaps here.
Before lifestyle options I was my mother’s caregiver. She was battling with cancer for 9 months. I did bed baths, doctors appointment, changed her colostomy bag, feed, personal care.
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
Militza Garcia

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
October 13, 2019
This application has been submitted and can no longer be edited.