Your Name* , Present Address* Contact Number* homecellother Second Contact homecellother 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?* Please leave this field empty. Share this:
