Caregiver Job Application


APPLICANT INFORMATION

Application Status
Draft
Name (First, Middle, Last)
Jocelyn Granada Miranda
Created: 12/20/2019
Other names under which employment may be verified:  
Updated: October 15, 2020

Home Address
Street Address
6147 n Claremont ave
Unit/Suite Number
City ST/Zip
Chicago , IL 60659
Home Phone
Mobile Phone
3127584237
Alternate Phone
Email Address

Have you ever worked for us before?   No
If no, how did you hear about us? Friend
Rate of pay desired.   15-18/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
No
What languages do you speak?   
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  Custom Home Care

How many years have you worked as a professional caregiver?  2
What percent of your previous case work has been for an agency?  8
Please explain how you will contribute to strengthen the Water Tower Nursing team.

To be more patience and to provide care to your client and respect their privacy in professional way.

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

My previous client is a hospice since she is COPD the kids don’t want their mom to suffer so they rely their mom in hospice care by giving morphine 3x a day and as a caregiver I’m just following what the family and hospice care instruction.

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   Graduate
Location:   Philippine
Did you graduate?   Yes
Subjects Studied   1987

College   Bachelor degree
Location:   Philippine
Did you graduate?   Yes
Degree:   1992

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
Private client (Jack Leblejian)
Phone
Daughter (773-744-2892
Address

2112 w Farwell ave.chicago

Supervisor
Job Title
Caregiver
Salary or Rate of Pay
20/hr
Responsibilities
Care
From
10/16/2019
To
12/26/2019
Reason for Leaving
May we contact this employer?  Yes

Company Name
Custom Homecare
Phone
1773-561-4663
Address

2716 w peterson Avenue Chicago 60659

Supervisor
Job Title
Caregiver
Salary or Rate of Pay
15/hr
Responsibilities
Care
From
10/24/2019
To
12/25/2019
Reason for Leaving
May we contact this employer?  Yes

Company Name
Eugene Home Care
Phone
1847-809-4796
Address

Gold road il

Supervisor
Lydia Budiongan
Job Title
Caregiver
Salary or Rate of Pay
13/hr
Responsibilities
Hospice patient
From
09/04/2019
To
09/20/2019
Reason for Leaving
Client 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.
My last client just passed away last November 20
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
William Zimmerman
Phone
1773-756-7538
Address
1501 oak ave Evanston il
Relationship
Son of my previous client

Name
Lydia Budiongan
Phone
1847-809-4796
Address
Crist hill il
Relationship
Previous employer

Name
Karen Benarez
Phone
1309-585-8383
Address
Clark ave Chicago
Relationship
Friend
Additional Information
Feel free to add any notes or additional information to your application in the space provided below.

I’m also a nurse in profession and planning to refresh since I stop working almost decades

Thank you for entering your employment history. If gaps exist in your employment history, please explain the gaps here.
My last client just passed away last November 20
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
Jocelyn G.Miranda

PART FIVE – APPLICATION SUBMISSION

Application Status
Draft
Date Submitted