Dubols Home Care - Elder Care Provider Application Form

PERSONAL INFORMATION:

Name (First/Last): SSN: Email:

Address: City:

County: State: Zip:

Home phone: Best time to call:

Cell phone: Best time to call:

DOB: Marital Status: Single Married Divorced

Gender: Male Female Weight: Height:

Emergency Contact Name: Emergency Contact Number:

BACKGROUND:

Is English your first or second language? 1st 2nd

What other languages do you speak fluently?

What is your Nationality?

Have you ever been convicted of a crime? Yes No If yes please explain below.

A "yes" answer will not automatically disqualify you from employment but will be considered only as it is relevant to employment and compliance with state law.

Are you 18 years or older? Yes No

Are you legally entitled to work in the U.S.? Yes No

Do you drive a car? Yes No

Will you drive your car to work? Yes No
Drivers License Number: Issued State:

Do you smoke? Yes No

Are you a U.S. citizen? Yes No

If not, are you a resident alien? Yes No Alien Registration Number:

EDUCATION:

High School Name: Location:

Diploma Received? Yes No

College Name: Location:

Attended from: Attended to:
Degree Earned:
Major/Minor:

Vocational/Nursing School: Location:

Attended from: Attended to:
Certificate/Diploma:

WORK EXPERIENCE:

Years of professional elder care experience:

Type of experience:

Explain your experience with the following:

Companion Care (shopping, errands, etc.) :

Personal Care (bathing, dressing, etc.) :

Housekeeping (dusting, vacuuming, etc.) :

Cook/Prepare Meals (What foods you can cook) :

Do you have Pediatrics Experience? Yes No

WORK PREFERENCES:

Will you accept (check all that apply): FT PT PRN Temporary Days Evenings
Nights Weekends Live-in Assignments

Would you be willing to relocate? Yes No
If so, where?

Are you willing to commit to a one-year employment contract? Yes No

Are you willing to work with children? Yes No

Can you work with clients who smoke? Yes No

Are you willing to work in a home with pets? Yes No

If so, are you willing to help with pet care? Yes No

Available for Emergency/Short Term? Yes No

PROFESSIONAL LICENSE/CERTIFICATION:

CNA/GNA License/Cert. Number: State Issuing LIcense/Cert.:

Are you experienced working with the following (check all that apply):
Blood Pressure Check Glucose Blood Sugar Check Colostomy Bag Insulin Shots Feeding Tube
First Aid Certified CPR Certified Alzheimer's/Dementia Cancer Diabetes Hospice

Type: Geriatric Nursing Assistant Certified Medicine Aide HHA Companion

Are you Certified Med. Administrator or Med. Tech.? Yes No

EMPLOYMENT HISTORY:

Employer 1 Name:

City:    State:   Zip:
Position:        From:      To:
Phone Number:
Starting Salary:    Ending Salary:

Describe job responsibility:

Reason for leaving:
May we contact Employer? Yes No
Supervisor Name & Phone Number:

Employer 2 Name:

City: State:   Zip:
Position:        From:      To:
Phone Number:
Starting Salary:    Ending Salary:

Describe job responsibility:

Reason for leaving:
May we contact Employer? Yes No
Supervisor Name & Phone Number:

Employer 3 Name:

City:     State:   Zip:
Position:         From:      To:
Phone Number:
Starting Salary:    Ending Salary:

Describe job responsibility:

Reason for leaving:
May we contact Employer? Yes No
Supervisor Name & Phone Number:

How were you reffered to us?

CERTIFICATION AND RELEASE: I certify that I have read and understand the application note on page one 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. 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. CHECK HERE IF YOU AGREE:

Type Your Name: Type Date:

Signature: ________________________________________________________ Date: __________________

If submitting form via this online form, you will be asked to sign when visiting our office.

If you feel uneasy submitting your personal information over the Internet, please print this form and send it to us via postal service. By submitting this form via Internet, you indemnify Dubols of any responsibilities for the misuse of personal information by others.