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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