Caregiver Job Application


APPLICANT INFORMATION

Application Status
Draft
Name (First, Middle, Last)
Kent TESTING Smith
Created: 05/24/2019
Other names under which employment may be verified:  none
Updated: October 16, 2020

Home Address
Street Address
21398 Sumac Court
Unit/Suite Number
City ST/Zip
Deer Park, IL 60010
Home Phone
8477076017
Mobile Phone
8477076017
Alternate Phone

Have you ever worked for us before?   No
If no, how did you hear about us? your awesome website!
Rate of pay desired.   $20/hr
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
No
Dogs
No
Smoker
No
What languages do you speak?   english
Do you have any caregiver training from other home services agencies?  Yes
If yes, explain.  From Acme Caregivers in Chicago IL

How many years have you worked as a professional caregiver?  6
What percent of your previous case work has been for an agency?  90
Please explain how you will contribute to strengthen the Water Tower Nursing team.

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

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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   Main High School
Location:   Chicago, IL
Did you graduate?   Yes
Subjects Studied   General Studies

College   Chicago Community College
Location:   Chicago, IL
Did you graduate?   No
Degree:   Health & Services

Other:   
Location:   
Did you graduate?   
Degree:   

Special awards you earned or courses you have taken.
Perfect attendance in high school

Military Service

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

Licenses and Certifications

EMPLOYMENT HISTORY

Company Name
Test Company
Phone
312-555-4321
Address

131 S Lake Shore Drive
Chicago, IL 60606

Supervisor
Jane Doe
Job Title
Assistant Manager
Salary or Rate of Pay
$20
Responsibilities
assist with things
From
08/13/2019
To
08/15/2019
Reason for Leaving
More money
May we contact this employer?  Yes

Company Name
World's Best Caregivers
Phone
312-555-1212
Address

1 North Main St
Chicago IL 60606

Supervisor
Jane Doe
Job Title
Sr Caregiver
Salary or Rate of Pay
$15
Responsibilities
in home caregiver for two clients
From
11/01/2008
To
08/19/2011
Reason for Leaving
I moved
May we contact this employer?  Yes

Company Name
Acme Caregivers
Phone
312-555-1212
Address

123 Main St
Chicago, IL 60606

Supervisor
John Doe
Job Title
Caregiver
Salary or Rate of Pay
$15
Responsibilities
in home caregiver for various clients
From
02/05/2018
To
01/02/2019
Reason for Leaving
Client no longer needed services
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 family needed me to stay at home and care for our children
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
Michael Jordan
Phone
312-444-5555
Address
876 Elm, Chicago IL
Relationship
friend

Name
Jay Cutler
Phone
312-555-9876
Address
6744 Baker St, Barrington IL
Relationship
friend

Name
Jackson Browne
Phone
888-777-6767
Address
878 7th St, Memphis TN
Relationship
friend
Additional Information
Feel free to add any notes or additional information to your application in the space provided below.

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Curabitur non nulla sit amet nisl tempus convallis quis ac lectus. Vivamus magna justo, lacinia eget consectetur sed, convallis at tellus. Curabitur arcu erat, accumsan id imperdiet et, porttitor at sem. Pellentesque in ipsum id orci porta dapibus. Curabitur arcu erat, accumsan id imperdiet et, porttitor at sem.

Thank you for entering your employment history. If gaps exist in your employment history, please explain the gaps here.
My family needed me to stay at home and care for our children
Additional Certifications
No additional certifications

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
Kent TESTING Smith

PART FIVE – APPLICATION SUBMISSION

Application Status
Draft
Date Submitted