Can you Prepare Meals?
If Yes, what language ?
Yes, I have read the Applicants Statement.
Date and Submit
If Yes, please describe
Date and time
Read / Date / Submit
Vl. Military Services - Have you obtained any special skills or abilities as a result of the services in the military that would be beneficial to the position you are applying for ?
Vll. Personal References: Please list (3) persons NOT related to you, which you have known for at least three (3) years. Include: Name, Address and Contact Number
List any other office machine you can operate.
What knowledge, special skills and or individual capabilities do you have, which especially prepared you for the position applied for ?
Education / College or University- Name & City of School / Number Years Completed / Did you Graduate - Y/N ? / Type of Degree / Major Field(s) of Study.
lV. Education / High School or Trade: List- Name & City of School / Number Years Completed / Did you Graduate - Y/N ? / Major Field(s) of Study.
V. Employment History - Please account for all employment within the last two years , beginning with your current or more recent employer. Provide:Position Held/ Company Name/Address/Phone/Dates: From-To/Salary/Job Title/Hours&Days Worked/Supervisor/Current employer-Y/N- Can we contact employer-Y/N-Specific Job Duties.
If Yes, what type of computer software are you proficient in ?
Do you have video calling such as a skype account ?
Are you able to operate a personal computer ?
If Yes, please provide type of service and your contact information.
In the Health Care field are you (check all that apply)
lll. Skills - Do you speak, write or understand any language other than English ?
Please list the closet to furthest geological area you are willing to travel to see a client, starting with your closest town.
Are you CPR certified ?
If No, please explain.
Are you able to perform the essential functions of the position for which you are applying ?
Do you like working one on one with people ?
When are you available to begin working ?
1 to 2 months
2 to 3 months
3 to 4 months
How will you be commuting to a clients home ?
Are you available to work night(s) ?
If, No was selected for the above questions , please explain here.
Days and hours you are available for work?
Have you ever been convicted of a criminal offense (felony or misdemeanor) ? Note: An affirmation answer will not neccessarily result in a disqualification for employment
If yes, please state nature of offense(s), Date(s), City, State, and disposition of the offense:
Drivers License Number
Date of Birth (Must be 18 to apply)
Indicate whether you are applying for a Volunteer or Salaried Position
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If hired can you provide proof that you are legally able to work in the United States?
How were you referred to us?
Social Security Number
Thank you for contacting us! If needed, you will hear back within 48-72 hours.
II. Employment - Position Desired (Check all that apply)
Are you willing to work overtime, if necessary ?
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