Careers Form

Equal Opportunity Employer

Qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, or marital status, or the presence of a non-related medical condition or disability. All questions must be answered and application signed. Any application that provides unrequested information will be automatically rejected.

Position(s) Applied for *

Date

Last Name *

First Name *

Middle Name *

Social Security Number *

Current Address:

City:

State:

Zip:

Email *

Home Phone Number: *

Cell Phone # *

Are you able to work overtime if required

Yes

No

Are you able to meet the attendance requirements of the position?

Yes

No

Have you previously applied for a position at LOVE TO CARE?

Yes

No

When?

Have you previously worked at LOVE TO CARE?

Yes

No

When?

Are you eligible to work in the United States?
(Proof of eligibility will be required before you can be employed.)

Yes

No

Are you presently on layoff and/or subject to recall from any other company?

Yes

No

If yes, please explain:

Have you ever been convicted of/or pleaded guilty to a crime (other than minor traffic violations) in the past seven years?

Yes

No

If yes, please explain: (give date, location, charge, etc.)

If the job requires, do you have a valid drivers license?

Yes

No

DL#

Type:

State of Issue

Have you had any moving violations in the past 3 Years?

Yes

No

If yes, please describe:

Do you have any relatives currently employed by Comfort Keepers?

Yes

No

If yes, please list:

What position are you applying for? (check one)

Live-in

Full time

Part-time

If you checked live-in, do you have experience doing live-in?

Yes

No

How many years?

Do hold an updated HHA or PCA certificate?

Yes

No

HHA

PCA

When are you available to start work?

Will you need time off within the next 3 months, vacation, doctor’s appointment, etc?

Yes

No

If yes, explain

Circle which days you available for work?

M

T

W

TH

F

S

Sun

am

pm

overnight

Do you have allegories/fears of dogs, cats, other?

Yes

No

Yes, explain

Are you available to work anytime during the weekend?

Yes

No

Are you able to cook and provide healthy meals to seniors?

Yes

No

Which types of foods can you cook well?
American African Italian Asian other

The job will entail maintaining the home and caring for the senior.

VG (for very good)

A (for adequate)

NT (for need training)

light housekeeping

preparing meals

companionship

laundry

listening skills

communication skills

flexibility

following directions

patience

If you arrive at the client’s home and no one answers the door, what would you do?

Would you feel comfortable working with the following?

Assisting a female senior in & out of the shower

Yes

No

Assisting a male senior in & out of the shower

Yes

No

Caring for someone with Alzheimer’s

Yes

No

Assisting a senior who is incontinent and needs a diaper changed

Yes

No

Caring for someone with Dementia

Yes

No

Are you comfortable around a smoker?

Yes

No

Yes, explain

What areas would you be available to work in? Circle all that apply:

Yes

No

What would you do if a client or their family yells at you or says something unkind?

In the past, who have you worked with?

Yes

No

If you had to go to an event but it was scheduled on your work time, how much time do you think is appropriate to give the agency?

If you are a live-in worker, which days are best for you?

Monday morning to Friday morning

Friday morning to Monday morning

Either one

Monday:

8	9	10	11	12noon	1	2	3	4
5	6	7	8	9	10	11	12midnight	overnights

Tuesday:

8	9	10	11	12noon	1	2	3	4
5	6	7	8	9	10	11	12midnight	overnights

Wednesday:

8	9	10	11	12noon	1	2	3	4
5	6	7	8	9	10	11	12midnight	overnights

Thurs:

8	9	10	11	12noon	1	2	3	4
5	6	7	8	9	10	11	12midnight	overnights

Friday:

8	9	10	11	12noon	1	2	3	4
5	6	7	8	9	10	11	12midnight	overnights

Sat:

8	9	10	11	12noon	1	2	3	4
5	6	7	8	9	10	11	12midnight	overnights

Sun:

8	9	10	11	12noon	1	2	3	4
5	6	7	8	9	10	11	12midnight	overnights

The least amount of hours I would like to work a day is

The least amount of hours I would like to work a week is

The maximum amount of hours I would like to work a week

Person to be contacted in case of an emergency:

Relationship:

Last Name

First Name

Middle Name

Telephone #:

Address:

City:

State:

Zip:

Type of School

Name/City

How Many Years Attended

1

2

3

4

Graduated

Yes

No

Course or Major

1

2

3

4

Yes

No

1

2

3

4

Yes

No

1

2

3

4

Yes

No

1

2

3

4

Yes

No

Employer:

Telephone:

Address:

Job Title:

Immediate Supervisor and Title:

Summarize the nature of the work performed and job responsibilities

From

To

$

Per

$

Per

Reason for leaving:

May we contact for reference / verification?

Yes

No

Later

Employer:

Telephone:

Address:

Job Title:

Immediate Supervisor and Title:

Summarize the nature of the work performed and job responsibilities

From

To

$

Per

$

Per

Reason for leaving:

May we contact for reference / verification?

Yes

No

Later

Employer:

Telephone:

Address:

Job Title:

Immediate Supervisor and Title:

Summarize the nature of the work performed and job responsibilities

From

To

$

Per

$

Per

Reason for leaving:

May we contact for reference / verification?

Yes

No

Later

List name and telephone number of three business/work references that are not related to you and are not previous supervisors. If not applicable, list three school or personal references that are not related to you, whom have knowledge of your work ethic, experience and abilities.

Name

Telephone

Years known

Relationship

I certify that the facts contained in this application and/or interview(s) are true and complete. Any misrepresentation or falsification of information or significant omissions will be cause for rejection of my application or for subsequent discipline up to and including my dismissal from employment if discovered at a later date.
I understand that, if employed, my employment is not guaranteed for any term, and my employment may be terminated by the employer or myself at any time and for any reason with or without prior notice. No representative of LOVE TO CARE other than the owner(s) is authorized to make any assurance or promise of continued employment and any such assurance must be in writing signed by the owner(s).

If I am employed, I agree to comply with and be bound by the safety and health rules and regulations, and rules of conduct of LOVE TO CARE.

This application will remain on active file for 60 days. If I am hired within this period, this form will be transferred to my individual personnel file. If I am not hired or have not heard from this employer within 60 days, this application is no longer active and I will need to reapply for employment if I wish to be considered for a job with LOVE TO CARE.
I give the employer and /or it’s agents, including consumer reporting bureaus, the right to investigate any and all statements made in this application for the purpose of employment and retention of employment. This investigation may include, but not limited to, credit reports, criminal conviction records, motor vehicle driving records and previous employment history. Further, I hereby release from liability and hold harmless this employer, its’ representatives, all persons and organizations/companies for furnishing such information.

If required, I agree to a drug testing prior and during employment or for post accident occurrences.

The employer, LOVE TO CARE, is an Equal Opportunity Employer. The employer does not discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state, or federal law.

NOTICE:

This is to inform you that as part of processing your employment application, we may obtain a consumer report and/or an investigative report that includes information as to your character, general reputation, personal characteristics and mode of living. If an investigative report is requested, you have the right to make a written request within a reasonable period of time for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. By signing below, you acknowledge receipt of a copy of this notice and a copy of the “Summary of Your Rights Under the Fair Credit Reporting Act.”

Signature of Applicant

Date