Employment Application Form

Your Name*
,

Present Address*
Contact Number*
Second Contact
E-mail Address*

Checked regularly* YesNo

How did you hear about us?* AdFrom EmployeeSomeone else


Position applying for*
Date Available*
Are you interested in:* Full time 30-40 hours/weekPart time 20- 30 hours/weekDay shiftsEvening shiftsOvernight shifts

Education
High School Diploma / GED* YesNo
College Degree* YesNo

Other Licenses and Certifications
Are you a CNA or HHA?* YesNo
Do you have a current CPR certification?* YesNo
If you answered Yes to any/both of these questions, please let us make a copy of the appropriate paperwork


Special Skills/Experience Caring for Elders

Experience caring for elders?* YesNo


Prior Applications

Have you applied at Elder Care Home Connections before?* YesNo
If so, when?

 

Work History (Previous 3 years)*
Please list your last three contactable places of work

Previous Employer 1
Supervisor:
Date started Date left

Job Title: Pay:
Valid Company phone number:
May we contact this employer? YesNo

Reason for leaving

Previous Employer 2
Supervisor:
Date started Date left

Job Title: Pay:
Valid Company phone number:
May we contact this employer? YesNo

Reason for leaving

Previous Employer 3
Supervisor:
Date started Date left

Job Title: Pay:
Valid Company phone number:
May we contact this employer? YesNo

Reason for leaving


Professional References*
It is essential for you to fill out current telephone numbers for all your references.


Name

Address

Valid Tel #
 

Name

Address

Valid Tel #
 

Name

Address

Valid Tel #

Because majority of our clients require care on weekends you will be required to work at least every other weekend. Are you available to work?* YesNo

We Serve in Monroe and other surrounding counties. You may be asked to serve in these surrounding counties. Can you work in these counties?* YesNo

Why have you chosen to work with the elderly?*

 

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Elder Care Home Connections, LLC

Professional Senior Home Care
  • Located in the South Court Professional Building
  • 239 E. Winslow Rd.
    Bloomington, IN  47401
  • Phone: (812) 330-3771
  • Fax (812) 287-8468
  • Email us
  • Staffed with experienced care providers who are available 24 hours a day, 365 days a year.

Map & Directions

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