Caregiver Job Application


APPLICANT INFORMATION

Application Status
Submitted
Name (First, Middle, Last)
Carrie Jackson
Created: 12/31/2019
Other names under which employment may be verified:  None
Updated: December 31, 2019

Home Address
Street Address
915 W. Wilson Ave., Apt. 422
Unit/Suite Number
City ST/Zip
Chicago, IL 60640
Home Phone
Mobile Phone
773-803-1849
Alternate Phone

Have you ever worked for us before?   Yes
If yes, when? NO. I have never worked for WTN before. I don’t know why it says YES. I tried to change it, but can’t.
Rate of pay desired.   13.75
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?   
Do you have any caregiver training from other home services agencies?  No
If yes, explain.  

How many years have you worked as a professional caregiver?  0
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 am ALWAYS professional in the work place. I can be flexible. I am a great listener. I am willing to learn, what it takes to be an excellent Home Health Aide.

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

I have no “professional experiences,” as a caregiver. But, did take care of my significant other during the last two years of his life...I helped him bathe/shower, did his laundry, prepared his meals. I shaved his hair, trimmed his mustache and beard, I also accompanied him to doctor’s appointments and helped take his medications, ETC. Took care of his cats needs as well. As a matter of fact, she’s with me today!

Availability

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

Education

High School   Hugh Manley High School
Location:   Chicago, IL
Did you graduate?   Yes
Subjects Studied   

College   Harry S. Truman College
Location:   Chicago, IL
Did you graduate?   No
Degree:   None

Other:   
Location:   
Did you graduate?   
Degree:   

Special awards you earned or courses you have taken.
Beginning Computer Skills

Military Service

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

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
Whole Food Market
Phone
Address

30 W. Huron

Supervisor
Job Title
Salad Bar Clerk/Whole Foods Team Member
Salary or Rate of Pay
9.50hr
Responsibilities
Making “packaged items,” like TV dinners, fresh lemonade(in individual cups), making WFM holiday snacks, packaged salads/sandwiches. Cooking for the hot bar. Also, prepared for the salad bar.
From
04/04/2005
To
04/03/2009
Reason for Leaving
I asked to be transferred to a newer/bigger store
May we contact this employer?  Yes

Company Name
Whole Food Market
Phone
Address

1550 N. Kingsbury Court

Supervisor
Job Title
Salad Bar Clerk/Prepared Foods Team Member
Salary or Rate of Pay
13.50hr
Responsibilities
Preparing fruit/vegetables by cutting, dicing, slicing...Following food sanitation guidelines. Set up the salad bar, in the mornings and refilling it throughout the day. In evenings, I put away OR discarded ALL foods that would spoil, if kept. Recorded any “outdated product and discarded.” And, cooking daily.
From
04/06/2009
To
10/08/2010
Reason for Leaving
Did not like the turn that the company took.
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.
The huge gaps in my employment are due to chronic ailment/illness. I have nursed myself through “proper/professional,” medical care. I am now, doing well.
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
Phone
Address
Relationship

Name
Phone
Address
Relationship

Name
Phone
Address
Relationship
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.
The huge gaps in my employment are due to chronic ailment/illness. I have nursed myself through “proper/professional,” medical care. I am now, doing well.
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
Carrie Jackson

PART FIVE – APPLICATION SUBMISSION

Application Status
Submitted
Date Submitted
January 1, 2020
This application has been submitted and can no longer be edited.