Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Maria San Gaspar Falcon
Created: 12/02/2019
Other names under which employment may be verified:  Maggie
Updated: December 17, 2019

Home Address
Street Address
3109 N. Kilpatrick Ave.
Unit/Suite Number
City ST/Zip
Chicago, IL 60641
Home Phone
Mobile Phone
312-925-1510
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us? Friends
Rate of pay desired.   20-25/ hr.
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
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.  By your side ,Alpha-omega Agency.CMK CNA school.

How many years have you worked as a professional caregiver?  20
What percent of your previous case work has been for an agency?  70
Please explain how you will contribute to strengthen the Water Tower Nursing team.

I am very professional and serious about My Job.I am well oriented and trained. I am good of what I do. I know I can contribute to the water tower nursing team.

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

I am a reliable person with a lot of experienced.I am flexible and work with different cases.Such as Dementia, Parkinson’s,Hospice, ambulatory, G- tube, Diabetic and a lot more.

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   GRDHS
Location:   Catanduanes, Philippines
Did you graduate?   Yes
Subjects Studied   Full curriculum

College   Centro Escolar University
Location:   Manila Philippines
Did you graduate?   Yes
Degree:   Bachelor of Arts in Economics

Other:   CMk school
Location:   Carol stream
Did you graduate?    Yes
Degree:   Certified Nursing Assistant

Special awards you earned or courses you have taken.
License Insurance Producer

Military Service

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

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
Alpha omega
Phone
708-323-5840
Address

292 Paddock circle
Glendale heights, Illinois

Supervisor
Helen Moraga
Job Title
Caregiver
Salary or Rate of Pay
15/hr.
Responsibilities
Caregivers for various clients.
From
01/20/2016
To
12/09/2016
Reason for Leaving
No clients available
May we contact this employer?  Yes

Company Name
By Your side
Phone
1- 630 - 7179-119
Address

23 E. Hinsdale st.
Hindsdale Il.

Supervisor
Carol
Job Title
Caregiver
Salary or Rate of Pay
16/hr.
Responsibilities
Taking care of Dementia Patients.
From
05/02/2016
To
09/30/2018
Reason for Leaving
Patients move to the skilled nursing Facility.
May we contact this employer?  Yes

Company Name
Joyce Rubeinstein
Phone
312 - 587-0120
Address
Supervisor
Jan Rubeinstein
Job Title
CareGiver
Salary or Rate of Pay
300 per 25 hours shift.
Responsibilities
Companion/ sitter.
From
03/01/2019
To
12/03/2019
Reason for Leaving
Current ( still working) need more hours.
May we contact this employer?  Yes

Company Name
June Kanner
Phone
1-773 -871-7652
Address

2480 Greenview
Chicago Illinois.

Supervisor
June
Job Title
CareGiver
Salary or Rate of Pay
17/ hr
Responsibilities
Taking care of her husband with a G- tube conditions. And Assisting ADL to the Patients.
From
11/01/2018
To
08/24/2019
Reason for Leaving
Patient Died.
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.
Sometimes I have to attend to the needs Of my family, therefore i choose not to work.
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
Estan panopio
Phone
773- 396-7153
Address
Relationship
Friend

Name
June Kanner
Phone
1773 8717652
Address
Relationship
Wife of my patient.

Name
Sarah Michaelis
Phone
16307825835
Address
Relationship
Daughter of my Patients.
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.
Sometimes I have to attend to the needs Of my family, therefore i choose not to work.
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
Maria san Gaspar Falcon

PART FIVE – APPLICATION SUBMISSION

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