Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Sanije Qirjaqi
Created: 06/04/2019
Other names under which employment may be verified:  Sophia
Updated: November 7, 2019

Home Address
Street Address
1555 N. Dearborn Pkwy
Unit/Suite Number
Apt. 8C
City ST/Zip
Chicago, IL 60610
Home Phone
Mobile Phone
8476604459
Alternate Phone
Email Address

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

How many years have you worked as a professional caregiver?  6
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.

I will work to build on and improve your vision and mission in supporting and taking care of clients. My strengths include building positive relationships, going above and beyond for my clients/employers, and improving their lives.

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

I was dedicated to an elderly man for 7 years until he passed away at 101 years old. Some of the tasks I was in charge of included:
Set and maintained a daily schedule of the elderly individual.
• Scheduling included planning of doctor’s appointments, grocery shopping, barber and
beauty shop appointments, and family and friends lunches.
• Prepared meals throughout the day for the elderly individual.
• Ensured safety codes within the home to minimize walking accidents.
• Providing daily baths for the elderly individual.
• Accompanied the individual in social events and promoted healthy relationships with peers,
as individual was reserved and shy.
• Ensured he was involved in social events daily.

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   Professional School of Languages
Location:   Tirane, Albania
Did you graduate?   Yes
Subjects Studied   Professional Degree of the English language.

College   College of DuPage
Location:   Glen Ellyn, IL
Did you graduate?   Yes
Degree:   Associate Degree in Arts and Paraprofessional in Education Certificate

Other:   Oakton Community College
Location:   Skokie, IL
Did you graduate?    Yes
Degree:   Elder Care Support Certificate (PES)

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
Private
Phone
847-345-3823
Address

VI Assistant Living
2500 Indigo Lane, Apartment 376
Glenview, IL 60026

Supervisor
Arnee J. Eisenberg
Job Title
Personal assistant and care taker
Salary or Rate of Pay
$25.24/hour
Responsibilities
• Set and maintained a daily schedule of the elderly individual. • Scheduling included planning of doctor’s appointments, grocery shopping, barber and beauty shop appointments, and family and friends lunches. • Prepared meals throughout the day for the elderly individual. • Ensured safety codes within the home to minimize walking accidents. • Providing daily baths for the elderly individual. • Accompanied the individual in social events and promoted healthy relationships with peers, as individual was reserved and shy. • Ensured he was involved in social events daily.
From
06/01/2012
To
10/14/2018
Reason for Leaving
Patient passed away
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.
There aren't any.
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
Ms. Nadine Fraulini
Phone
847-245-3445
Address
nfraulini@comcast.net
Relationship
Previous supervisor

Name
Dr. Carolyn Zaslaw
Phone
415-307-1755
Address
czaslaw@sbcglobal.net
Relationship
Client's daughter

Name
Mrs. Denise Schrager
Phone
847-571-6252
Address
dnschrager@hotmail.com
Relationship
Client's niece
Additional Information
Feel free to add any notes or additional information to your application in the space provided below.

Additional experience:
❖ Sophia’s cleaning, Self-Employed, Chicagoland area, IL, 2000-2012
• Self employed home cleaner.
❖ Kindergarten Teacher, Berxul Elementary and Middle School, Tirane, Albania, (17 years) • Ensured students’ safety and wellbeing while teaching the curriculum.

I also like to contribute to my community and volunteer at a store where profits go to 15 charities in the Chicagoland area to assist women and families in need.

Thank you for entering your employment history. If gaps exist in your employment history, please explain the gaps here.
There aren't any.
Additional Certifications
❖ Oakton Community College, Skokie, IL, June 2016 • Elder Care Support Certificate (PES). ❖ College of DuPage, Glen Ellyn, IL, May 2013 • Paraprofessional in Education Certificate. ❖ College of DuPage, Glen Ellyn, IL, May 2013 • Associate Degree in Arts. ❖ Professional School of Pedagogy, Tirane, Albania, Graduated May 1978 • Professional Degree of Teaching in Elementary Education. ❖ Professional School of Languages, Tirane, Albania, Graduated May 1973 • Professional Degree of the English language. ❖ Language Background, Ongoing • Languages include Albanian, Greek, English, and Spanish (polite level).

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
Sanije Qirjaqi

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
June 4, 2019
This application has been submitted and can no longer be edited.