Caregiver Employment - Caregivers in Fresno, Clovis and Madera

Name*

First Middle Last

Date*

Are you fully vaccinated against COVID-19?*

State and local guidelines require all home care aides must be vaccinated.

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

SSN

Email*

HCA #

I am applying for a position as a (i.e., caregiver, administrator, etc.):*

How did you hear about us?

Emergency Contact

Name*

First and Last

Phone*

Address*

Relationship*

Transportation

Many caregiver positions require transporting our clients.

Do you have dependable transportation?*

Yes
No

Do you have a valid driver licence?*

Yes
No

Any "At Fault" automobile accidents in the last 3 years?*

No
Yes - 1
Yes - more than 1

Any major violations in the last 3 years?*

No
Yes - 1
Yes - more than 1

Any moving violations in the last 3 years?*

No
Yes - 1
Yes - more than 1

Any DUI or DWI violations?*

No
Yes - 1
Yes - more than 1

Licence Plate #*

Make and model car*

Auto insurance policy #*

Insurance company*

Insurance agent name

Insurance phone*

Availability

Number of hours you would like to work*

Times you are available to work*

Any times not available

Can you be called at the last minute in case of emergency?*

Yes
No

Comments

Education

High School*

City/State*

Graduated*

Yes
No

College

City/State

Graduated

Yes
No

Other

City/State

Completed

Yes
No

Degrees/Certificates

Special Skills or Courses

Experience

Discuss any training or experience working with the elderly.

What would you like most about working with the elderly?

What would you like least about working with the elderly?

Skills

Please indicate which of the following tasks you have assisted with or performed for seniors.

I have assisted with or performed for seniors:

Employment History

Please go back at least five years and tell us about your work history.

May we contact your current employer?

Yes
No
I am currently unemployed

Company

From

To

Job Title

Reason Left

Duties

Supervisor

Phone

Company

From

To

Job Title

Reason Left

Duties

Supervisor

Phone

Company

From

To

Job Title

Reason Left

Duties

Supervisor

Phone

Company

From

Job Title

To

Reason Left

Duties

Supervisor

Phone

Business References

(Non-family only) Minimum of 3

Name

Address

Relationship/Years known

Local phone #

Name

Address

Relationship/Years known

Local phone #

Name

Address

Relationship/Years known

Local phone #

Name

Address

Relationship/Years known

Local phone #

Personal References

(Non-family only) Minimum of 3

Name

Address

Relationship/Years known

Local phone #

Name

Address

Relationship/Years known

Local phone #

Name

Address

Relationship/Years known

Local phone #

Name

Address

Relationship/Years known

Local phone #

CERTIFICATION AND RELEASE:

I certify that I have read and understand the application note at the beginning of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. Applications will be held for 60 days.

Sign Here

Date

Consent*

I agree to the privacy policy.

By submitting this form, you agree to the Privacy Policy (angelicare.com/privacy) and agree to be contacted by telephone or email.

Name

This field is for validation purposes and should be left unchanged.

Employment Application

Emergency Contact

Transportation

Availability

Education

Experience

Skills

Employment History

Business References

Personal References

CERTIFICATION AND RELEASE: