* = Required Information
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.


Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Availability Form 1
Live-in Full time Part-time
Yes No
Yes No
HHA PCA
Yes No
M T W TH F S Sun am pm overnight
Yes No
Yes No
Yes No

American African Italian Asian other

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

Rate yourself by putting:


Would you feel comfortable working with the following?

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Yes No
Yes No
Monday morning to Friday morning Friday morning to Monday morning Either one
Availability Form 2
Put an X on the times you are available to work:
8 9 10 11 12noon 1 2 3 4
5 6 7 8 9 10 11 12midnight overnights
8 9 10 11 12noon 1 2 3 4
5 6 7 8 9 10 11 12midnight overnights
8 9 10 11 12noon 1 2 3 4
5 6 7 8 9 10 11 12midnight overnights
8 9 10 11 12noon 1 2 3 4
5 6 7 8 9 10 11 12midnight overnights
8 9 10 11 12noon 1 2 3 4
5 6 7 8 9 10 11 12midnight overnights
8 9 10 11 12noon 1 2 3 4
5 6 7 8 9 10 11 12midnight overnights
8 9 10 11 12noon 1 2 3 4
5 6 7 8 9 10 11 12midnight overnights

Person to be contacted in case of an emergency:
Educational Background:
1 2 3 4
Yes No
1 2 3 4
Yes No
1 2 3 4
Yes No
1 2 3 4
Yes No
1 2 3 4
Yes No
Employment History:

List your last three (3) employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in comments section below.

Dates Employed
Month & Year
Hourly Rate/Salary
Starting
Hourly Rate/Salary
Final
Yes No Later
Dates Employed
Month & Year
Hourly Rate/Salary
Starting
Hourly Rate/Salary
Final
Yes No Later
Dates Employed
Month & Year
Hourly Rate/Salary
Starting
Hourly Rate/Salary
Final
Yes No Later
References:
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.
  • 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.”

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