HOME CARE SERVICES
CAREGIVER OPPORTUNITIES
- BECOME A CAREGIVER
- CAREGIVER JOB APPLICATION
ABOUT US
RESOURCES
CONTACT US

HOME CARE SERVICES
CAREGIVER OPPORTUNITIES
- BECOME A CAREGIVER
- CAREGIVER JOB APPLICATION
ABOUT US
RESOURCES
CONTACT US

Caregiver Job Application

Caregiver Job Application Form

Caregiver Job Application Form

First Name:

Last Name:

Street Address:

City, State, & Zip Code:

Email:

Phone:

Date of Birth:

Have you applied with HomeAides before?

Are you authorized to work in the US?

How did you hear about HomeAides?

Do you have friends/relatives working for HomeAides?

If yes, please list their names:

Are you currently employed?

If yes, name of employer:

Are we able to contact your employer?

Date available for work:

Number of hours per week desired:

Shift available to work:

Are you able to work weekends?

Are you able to work holidays?

Do you have a valid driver's license?

Are you willing to travel for work?

Area you can work:

List any certifications you have:

How would you rate yourself in Companionship (3 being the highest)?

1

2

3

How would you rate yourself in Dressing/Grooming (3 being the highest)?

1

2

3

How would you rate yourself in Meal Preparation (3 being the highest)?

1

2

3

How would you rate yourself in Light Housekeeping (3 being the highest)?

1

2

3

How would you rate yourself in Incontinence Care (3 being the highest)?

1

2

3

How would you rate yourself in Bathing/Showering (3 being the highest)?

1

2

3

How would you rate yourself in Shaving (3 being the highest)?

1

2

3

How would you rate yourself in Light Housekeeping (3 being the highest)?

1

2

3

How would you rate yourself in Alzheimer's/Dementia Care (3 being the highest)?

1

2

3

Do you consider yourself able to perform all the essential functions of the job for which you are applying for with or without accommodations?

List your education (high school/GED/trade school/college) if it is not listed on your resume:

Have you ever been convicted of any crime other than a minor traffic violation?

If yes, list details of each conviction:

List your employment history (past 2-3 jobs) if it is not listed on your resume:

List 2-3 references (names & phone numbers) if they do not appear on your resume:

Attach Resume:

Thank you for applying!

We will get back to you as soon as possible.

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Caregiver Opportunities

BECOME A CAREGIVER
CAREGIVER JOB APPLICATION

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ABOUT US
RESOURCES
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Contact Us

814-920-4492 cslomski@homeaidesnow.com

4934 Peach Street, Suite B1, Erie, PA 16509

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