Desired Wage Amount: How many hours can you work weekly?
4-16 16-26 26-40
When do you want to work your shift?
Day Night Weekend
Type Of Employment Desired: Part time live in Full time live out Part time live out Live in full time On call
What date are you available to start work?
NOTES
WORK EXPERIENCE: JOB 1
Name Of Business/Employer: Job Title/Position
Employment Dates: Employment Dates
Phone/Email
Location
Person to Contact
Position in Company
Can we contact your most recent client
Cana representative from our company contact your most recent employer?
Cana representative from our company contact your most recent employer?
YES NO
TRANSPORTATION
Do you currently hold a driver’s licence?
YES NO
What is your current mode of transportation?
Driver’s License Number#
Location where the licence was issued
Licence Expiration Date
Would you be willing to provide a driving record?
YES NO
Any driving accidents in the past three years?
YES NO
How many?
If Yes, Please Explain: Any driving violations in the past three 3 yrs?
YES NO
If Yes, Please Explain: COMMUNICATION
Check The Technology Devices That You Use: Cell Computer Tablet
Do you have a data plan on your mobile device?
YES NO
Will you be willing to fill out a caregiver daily checklist after each visit?
YES NO
Additional Notes: PERSONAL REFERENCE CONTACTS (Excluding family members)
Name
Connection
Phone
Email
Have they been notified that they are a reference?
YES NO
EDUCATION INFORMATION
LEVEL OF EDUCATION
NAME OF SCHOOL
PROGRAM
COMPLETED
LEVEL OF EDUCATION
NAME OF SCHOOL
PROGRAM
COMPLETED
LEVEL OF EDUCATION
NAME OF SCHOOL
PROGRAM
COMPLETED
RECOGNITION(S) OR ACCOMPLISHMENT(S)
LIST BELOW
Date
LIST BELOW
Date
LIST BELOW
Date
CRIMINAL BACKGROUND
Have you ever been charged with a criminal offence?
YES NO
If So, Please Explain: PLEASE READ CAREFULLY
I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the employer permission to contact schools, previous employers (unless otherwise indicated), and references.
This is an equal employment chance employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, or age. We assure you that your opportunity for this employment position depends solely on your qualifications.
Full Name of Applicant
DATE
Thank you for completing this application form and for your interest in our company.