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info@careplustlc.com
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Home
About
Meet Our Team
Services
Accident & Injury Care
Personal Care (ADLs)
Homemaking Services
Companion Care
Respite Care
Skilled Nursing Care
Home Health Aide (HHA) Services
Specialized Neurological Care
Gallery
Blog
Service Areas
Careers
Contact
Free Consultation
Application Form
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We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, medical condition, national origin, or marital status.
Personal Information
First Name
*
Last Name
*
Social Security Number
*
Home Phone
*
Work Phone
Mobile Phone
Email
*
Address 1
*
Address 2
City
*
State
Alabama
Alaska
American Samoa
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Northern Mariana Islands
Ohio
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Armed Forces Americas
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Zip
*
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US
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AR
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DC
FL
GA
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ID
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IA
KS
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ME
MD
MA
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AA
AE
AP
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WA
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WY
CA
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AB
BC
MB
NB
NL
NT
NS
NU
ON
PE
QA
SK
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Section 1 - General Information
Do you have a reliable car to drive to work?
*
Yes
No
Date Available?
*
MM slash DD slash YYYY
Job Type?
*
Full-Time
Part-Time? Set Schedule
On Call
Any
Can you provide documentation of a driver's license and auto insurance?
*
Yes
No
Driver License Expiration Date:
*
MM slash DD slash YYYY
Auto Insurance Expiration Date:
*
MM slash DD slash YYYY
Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other?
*
Yes
No
If yes, please explain.
Birthdate
*
MM slash DD slash YYYY
Section 2 - Availability
Do you prefer AM / PM or either
*
-- Select an Option --
Day Shift
Night Shift
Both / Either
Do you currently or have you ever worked as a caregiver outside of an agency?
*
Yes
No
Days of the Week you are available?
*
-- Select an Option --
All 7 days Open availability
Available some weekends
Available some holidays
I need to be scheduled around other job
Are you currently working for another agency?
*
Yes
No
Section 3 - Employment Verification
Are you a U.S. citizen?
*
Yes
No
If you are not a U.S. citizen, please indicate VISA type and number.
Are you authorized to work in the U.S.?
*
-- Select an Option --
I am authorized to work in the U.S. for any employer.
I am authorized to work in the U.S. only for my current employer.
I require sponsorship to work in the U.S.
I do not know my work status.
Section 4 - Education
Name of High School:
*
Location of High School:
*
Did you graduate?
*
Yes
No
Years Attended (From/To):
*
Did you Additional Education (vocational, undergraduate, etc.)graduate?
*
Yes
No
If yes, please list the name of the school and years attended (From/To)
Section 5 - Other Training: Certifications/Licenses
Certifications/Licenses:
Are you currently licensed as a:
*
-- Select an Option --
CNA
LPN
RN
Home Health Aide/ Caregiver
Years of experience as Home Caregiver?
*
-- Select an Option --
0-6 mos
1yr
2-4 years
5-10 years
Section 6 - Current Employment
Current Employer:
Address:
City:
State:
Zip Code:
Start Date:
MM slash DD slash YYYY
End Date:
MM slash DD slash YYYY
Hours Worked:
-- Select an Option --
Full Time
Part Time
Temporary
Position/Title:
Describe Your Responsibilities:
Supervisor's Name/Title:
Supervisor's Phone:
Reason for Leaving:
May we contact?
Yes
No
Section 8 - Employment History
Last Employer:
Address:
City:
State:
Zip Code:
Start Date:
MM slash DD slash YYYY
End Date:
MM slash DD slash YYYY
Hours Worked:
-- Select an Option --
Full Time
Part Time
Temporary
Position/Title:
Describe Your Responsibilities:
Supervisor's Name/Title:
Supervisor's Phone:
Reason for Leaving:
May we contact?
Yes
No
Section 9 - Reference 1
Name:
*
Company:
*
Phone:
*
Section 11 - Reference 2
Name:
*
Company:
*
Phone:
*
Section 13 - Emergency Contact Information
First Name:
*
Last Name:
*
Address:
City:
State:
Zip Code:
Phone 1:
*
Phone 2:
Relationship:
*
I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.
I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.
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