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First Name (required)

Last Name (required)

Address 1 (required)

Address 2

City (required)

State (required)

Zip Code

E Mail Address (required)

Contact Phone Number (required)

How Long Have you lived at Your Current Address? (required)

Position Applying For? (required)

How Did You Find About the Position

Are You 18 Years or Older? (required)

Have You ever Applied to ElderCare Before?

Are you able and willing to lift up to 50 pounds several times a day as needed in the function of care giving? (required)

Will You Consent to a Verification of your Work History? (required)

Do You Have Reliable Transportation to Work All Shift Hours? (required)

Can You Provide Documentation of a Valid Drivers License and Auto Insurance? (required)

Do You Have 2 or More Moving Violations in the Past 3 Years? (required)

Do You Have Any Moving Violations on Your Driving Record? (required)

If Yes Please List Violation and Date that the Violation Occured

Have You ever Worked Under Another Name? (required)

If yes Please List Other Names

How Many Years of Experience Do You Have Working in "Home Care"? (required)

Do You Have Experience Working with Clients that Have Dementia or Alzheimer's? (required)

How Many Years of Experience do You Have Working with Clients that Have Dementia or Alzheimer's?

Are you Capable of Reading, Writing, and Understanding English as a Part of your Job Performance? (required)

If You Can Speak Any Other Languages Other Than English Please List :

What is the Minimum Amount You Need to Earn Hourly? (required)

Are You a U.S. Citizen? (required)

Are You Authorized to Work in the U.S.? (required)

How Many Jobs Have You Had in the Last Year? (required)

Have You ever been Fired or Asked to Resign From a Position? (required)

What Date Would You be Available to Start? (required)

Do You Have any Obligations that We Need to Know About (ex Annual Trips, Vacations, Weddings, Reserve Duty, Hoilidays, etc...? (required)

If Yes Please Explain Below:

Are You Willing to Work Holidays? (required)

Would You be able to Work Flexable Hours? (required)

Are You Willing and Able to Work 12 Hour Shifts? (required)

Are You Willing and Able to Work Double Shifts? (required)

Are You Willing to Work Day Shifts? (required)

If Yes Which Day Shifts Can You Work?

Are You Willing to Work Evening Shifts? (required)

If Yes Which Evening Shifts Can You Work?

Are You Willing to Work Overnight Shifts? (required)

If Yes Which Overnight Shifts Can You Work?

Are You Willing to Work Live-In Shifts? (required)

If Yes Which Live-In Shifts Can You Work?

What Days and Times are You NOT Available to Work? (required)

What High School did You Attend? (required)

What is the Address of the School? (required)

Did You Graduate? (required)

What Years did You Attend From/To? (required)

Have You Completed any Additional Education (Vocational, College, Etc..)? (required)

If Yes Please List the School, Years Attended and Degree or Certificate Earned:

Do You Have a Current License in Good Standing from the State to which You are Applying? (required)

Please List your Current Licenses

Do You Have a Current Certificate in Good Standing from the State to which You are Applying? (required)

Please List your Current Certificates

Have You ever had a Certificate or License Suspended or Revoked? (required)

Please List the Date of Your Last TB Skin Test or Chest X-Ray: (required)

Have You ever been Fingerprinted for a Care Giving Job? (required)

Current Employer: (required)

Address: (required)

City: (required)

State: (required)

Zip Code: (required)

Start Date: (required)

End Date: (required)

Hours Worked (required)

Position/Title: (required)

Starting Wage: (required)

Describe Your Responsibilities: (required)

Supervisor's Name: (required)

Supervisor's Phone: (required)

Reason for Leaving: (required)

May We Contact? (required)