Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Wilfredo Rodriguez Gurrea
Created: 10/26/2019
Other names under which employment may be verified:  
Updated: November 14, 2019

Home Address
Street Address
5148 West George Street
Unit/Suite Number
City ST/Zip
Chicago, IL 60641
Home Phone
Mobile Phone
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us? Referred by Albert Borres
Rate of pay desired.  
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, tagalog
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  SCI Home Care

How many years have you worked as a professional caregiver?  4
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 have plenty of experience in this field. I'm able to work at any time.

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

I took care of an elderly man diagnosed with Parkinson's disease. Experience in helping with daily activities, such as bathing and bathroom functions, feeding, taking medication, and some housework. Assisting clients with ambulation and mobility around the house. I feel competent in performing caregiver duties and responsibilities.

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   Isabella Basilan High School
Location:   Basilan City, Philippines
Did you graduate?   Yes
Subjects Studied   

College   
Location:   
Did you graduate?   
Degree:   

Other:   
Location:   
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
Superb Home Care Corp.
Phone
2246226401
Address

2200 Devon Ave. Suite 353, Des Plaines, IL, 60018

Supervisor
Reynaldo Gobenciong
Job Title
Caregiver
Salary or Rate of Pay
$120 per day
Responsibilities
Caregiving
From
01/01/2016
To
09/01/2017
Reason for Leaving
Client transferred to Florida
May we contact this employer?  Yes

Company Name
Advent Home Care
Phone
6302920134
Address

415 Fernwood Drive, Westmont, IL, 60523

Supervisor
Josephine Padilla
Job Title
Caregiver
Salary or Rate of Pay
$140 per day
Responsibilities
Caregiving
From
09/01/2017
To
12/01/2018
Reason for Leaving
Relocation
May we contact this employer?  Yes

Company Name
Home For Good Senior Care, Inc.
Phone
7735724875
Address

6246 N Pulaski Rd, Chicago, IL 60646

Supervisor
Cecile
Job Title
Caregiver
Salary or Rate of Pay
$15 per hour
Responsibilities
Caregiving
From
01/01/2019
To
10/26/2019
Reason for Leaving
Still employed
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
Arnold Mapula
Phone
6308269607
Address
796 Pheasant Trail, St. Charles, IL
Relationship
Brother-in-law

Name
Epitacio Mapula
Phone
7734150597
Address
847 Pheasant Trail, St. Charles, IL
Relationship
Brother-in-law

Name
Rachelle Porter
Phone
7732942408
Address
Skokie, Illinois
Relationship
Niece
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)
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
Wilfredo R. Gurrea

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
October 26, 2019
This application has been submitted and can no longer be edited.