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Career Forms

Employment Application

Date Of Application:
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Date of Hire:
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Last Name:
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First Name:
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Home Phone:
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Middle Name:
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Soc. Sec. Number
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Date of Birth:
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Cell Phone:
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E-mail address:
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Street Address:
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City:
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State:
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Zip Code:
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Previous address(if less than 1 year)
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City:
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State:
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Zip Code:
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Desire Position:
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Available Start Date:
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Do you have a Driver’s License:
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License#:
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Exp. Date:
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Do you have a vehicle:
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Are you able to provide a valid Motor Vehicle Insurance:
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Are you a CNA/PCA/Homemaker/Companion:
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CNA License#:
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State:
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Are you willing to work in a client’s home that smokes:
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Are you willing to work in a client’s home that has pets:
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Do you have any allergies
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If yes, type of allergies:
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Are you able to perform the task according to the job description without accommodation:
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If any accommodation is needed, please explain
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Have you ever been convicted of a crime? If yes, please explain
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Have you ever been released from a job due to discipline of being fired? If yes, please explain
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WORK HISTORY

Recent Employer:
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Date(from)
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(to)
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Address:
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Position:
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Name of Supervisor:
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Phone:
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May we contact this supervisor:
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Please describe your job responsibilities:
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Recent Employer:
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Date(from)
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(to)
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Address:
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Position:
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Name of Supervisor:
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Phone:
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May we contact this supervisor:
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Please describe your job responsibilities:
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Recent Employer:
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Date(from)
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(to)
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Address:
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Position:
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Name of Supervisor:
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Phone:
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May we contact this supervisor:
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Please describe your job responsibilities:
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Name of High School
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Did you graduate?
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Dates attended
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Degree/Major
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Name of College
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Did you graduate?
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Dates attended
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Degree/Major
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Other Skills
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Did you graduate?
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Dates attended
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Degree/Major
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List any addition skills/background that you feel may be pertinent to the position that you are applying for

REFERENCES

(please provide two professional references and one personal)

Name:
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Address:
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Phone:
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Relationship:
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Years Known:
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Name:
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Address:
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Phone:
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Relationship:
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Years Known:
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Name:
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Address:
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Phone:
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Relationship:
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Years Known:
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We service ALL CT towns, please indicate the towns you are willing to work in
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What days and hours are you available to work?

DAY / MONDAY
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FROM
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TO
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Available for LIVE-IN
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OTHER
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DAY / TUESDAY
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FROM
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TO
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Available for LIVE-IN
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OTHER
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DAY / WEDNESDAY
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FROM
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Available for LIVE-IN
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OTHER
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DAY / THURSDAY
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FROM
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TO
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Available for LIVE-IN
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OTHER
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DAY / FRIDAY
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FROM
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TO
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Available for LIVE-IN
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OTHER
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DAY / SATURDAY
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FROM
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TO
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Available for LIVE-IN
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OTHER
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DAY / SUNDAY
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FROM
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TO
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Available for LIVE-IN
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OTHER
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I

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by signing this application, I certify that the information in this application is accurate, current and complete to the best of my knowledge. I understand that the omission of any required information may result in my immediate disqualification from further consideration or termination of employment with Love and Caring Homecare Agency. I agree that, if hired, I may be discharged if Love and Caring Homecare learns of any falsifications or material omission in the information I have provided and if discovered prior to hire, I would be ineligible for consideration not only for this position, but future positions with Love and Caring Homecare Agency, as well.

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