Caregiver Job Application


APPLICANT INFORMATION

Application Status
Draft
Name (First, Middle, Last)
Nicole R Bailey
Created: 10/16/2019
Other names under which employment may be verified:  
Updated: October 18, 2019

Home Address
Street Address
2606 w Balmoral ave #508
Unit/Suite Number
City ST/Zip
Chicago , IL 60625
Home Phone
773-308-3025
Mobile Phone
773-308-3025
Alternate Phone
Email Address

Have you ever worked for us before?   No
If no, how did you hear about us?
Rate of pay desired.   13 - hour
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
No
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.  Home/ Church

How many years have you worked as a professional caregiver?  5
What percent of your previous case work has been for an agency?  0
Please explain how you will contribute to strengthen the Water Tower Nursing team.

Offer excellent service

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

Prescription pick up
House cleaning
Light exercises
Bathing

Availability

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

Education

High School   John Adams
Location:   Aurora Colorado
Did you graduate?   Yes
Subjects Studied   Math and English

College   Wilfred academy of cosmetology
Location:   Chicago Illinois
Did you graduate?   Yes
Degree:   Cosmetology

Other:   Spirit rising yoga
Location:   Chicago
Did you graduate?    Yes
Degree:   Yoga Teacher Training

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
Rohini /moony
Phone
1-(773) 977-6185
Address

1716 w Lunt street Chicago Illinois 60626

Supervisor
Moony
Job Title
Home care
Salary or Rate of Pay
Twice a week $40
Responsibilities
Prescription pick up , leg massage, light house cleaning
From
To
Reason for Leaving
Husband passed away this year. Went back to India.
May we contact this employer?  Yes

Company Name
Vitamin Outlet
Phone
773-992-7983
Address

Clark and foster
Andersonville neighborhood

Supervisor
Govinda
Job Title
Customer service
Salary or Rate of Pay
9 hour
Responsibilities
Register - stocking - sales
From
04/01/2005
To
10/09/2013
Reason for Leaving
Vitamin outlet went out of business but the owner is available at jd mills in Evanston on Chicago ave
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.
I’ve been a house wife taking care of husband ect
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
Micheal
Phone
1-773-943-6043
Address
1440 Sherwin Ave Rogerspark
Relationship
Friend

Name
Hulio
Phone
‭+1 (847) 491-0940‬
Address
Evanston Chicago
Relationship
Friend

Name
Jay
Phone
+1 (630) 835-4097
Address
Lincolnpark Chicago
Relationship
Friend
Additional Information
Feel free to add any notes or additional information to your application in the space provided below.

Security guard training . Certified.

Thank you for entering your employment history. If gaps exist in your employment history, please explain the gaps here.
I’ve been a house wife taking care of husband ect
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
Nicole R Bailey

PART FIVE – APPLICATION SUBMISSION

Application Status
Draft
Date Submitted