Always There Home Care Application Form

Application Form

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - Personal Info

Emergency Contact - Name and Relationship (required)

Emergency Contact - Phone (required)

(Numeric Answer Only)

Birthday (month and day - year optional)

Section 2 - Position/Credentials

I am applying for a position as a: (required)

Certifications (required)

Have you ever been convicted of a felony? (required)

Yes No

If yes, please provide details

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Section 3 - Transportation. (Many caregiver positions require

Do you have reliable transportation? (required)

Yes No

Driver's License Number and State

If applicable, auto insurance company:

Auto insurance policy number

(Numeric Answer Only)

Section 4 - Availability

Number of hours you would like to work (required)

Days and times you are available to work (required)

Days and times NOT available to work (required)

Can you be called last minute in case of emergency? (required)

Yes No

Additional comments regarding availability

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Section 5 - Education

Highest Level of Education (required)

Special skills or courses related to position applied for

Section 6 - Relevant Experience

Please discuss any relevant training and/OR experience aronud working with the elderly

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What do you like most about working with the elderly? (required)

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What do you like least about working with the elderly? (required)

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Section 7 - Skills

Please indicate whether you have assisted with or performed the following tasks for seniors (required)

Please indicate whether you have assisted with or performed any of the following: (required)

Section 8 - Employment History

May we contact your current employer? (required)

Yes No

Please go back as long as five years and tell us about your work history

Company

Dates of employment

Job title and duties

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Supervisor name and contact phone number

Company

Dates of employment

Job title and duties

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Supervisor name and contact phone number

Company

Dates of employment

Job title and duties

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Supervisor name and contact phone number

Section 9 - Business References

Name

Address and contact phone number

Name

Years known

(Numeric Answer Only)

Address and contact phone number

Years known

(Numeric Answer Only)

Name

Contact address and phone number

Years known

(Numeric Answer Only)

Section 10 - Personal References

Name

Contact address and phone number

Years known

(Numeric Answer Only)

Name

Contact address and phone number

Years known

(Numeric Answer Only)

Name

Contact address and phone number

Years known

(Numeric Answer Only)

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

Signature