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Application Form
"
*
" indicates required fields
1
Personal Information
2
Work Preference
3
Education
4
Employment History
5
LinkedIn
This field is for validation purposes and should be left unchanged.
Personal Information
Name
*
First
Middle
Last
Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Email
*
Home Phone
Cell Phone
*
Gender
*
Male
Female
Open to Live-In Care
*
Yes
No
Convicted of a felony?
*
Yes
No
Vehicle Information
Vehicle Year
*
Vehicle Make
*
Driver's License
*
Yes
No
Experience
Experience
*
Alzheimer's
Bed Bath
Cancer
Combative
Dementia
Dementia Experience
Gait Belt Experience
Glucose Monitor
Hospice
Hospice Experience
Hoyer Lift Experience
Incontinence
Parkinson's
Stroke
Have you had a TB test in the last 3 years?
Yes
No
Result
Positive
Negative
Date Available
MM slash DD slash YYYY
Ideal Number of Hours Per Week
Expected Rate of Pay/hr
*
Shift Availability
Monday
Morning
Afternoon
Evening
Live-In
Tuesday
Morning
Afternoon
Evening
Live-In
Wednesday
Morning
Afternoon
Evening
Live-In
Thursday
Morning
Afternoon
Evening
Live-In
Friday
Morning
Afternoon
Evening
Live-In
Saturday
Morning
Afternoon
Evening
Live-In
Sunday
Morning
Afternoon
Evening
Live-In
Education
School Name
Subject Studied
Years Attended
Location
Degree
School Name
Subject Studied
Years Attended
Location
Degree
Reference
First Reference
Name
First
Relationship
Phone
Years Known
Second Reference
Name
First
Relationship
Phone
Years Known
Describe any personal, volunteer or work related experiences that will help you in this position:
Employment History
Present/Last Employer
Employer Name
Telephone
Supervisor's Name
May we contact?
*
Yes
No
Address
Position Title
From Date
MM slash DD slash YYYY
To Date
MM slash DD slash YYYY
Summary of Duties
Reason for Leaving
Previous Employer
Employer Name
Telephone
Supervisor's Name
May we contact?
*
Yes
No
Position Title
Address
From Date
MM slash DD slash YYYY
To Date
MM slash DD slash YYYY
Summary of Duties
Reason for Leaving
Certify
Certify
*
By signing this application, I certify this information to be true and agree to allow the above mentioned Home Care Agency to perform a criminal history background check, at their leisure, and I give permission for them to check my references.
Name
*
First
Date
*
MM slash DD slash YYYY
Signature
*
Employee Authorization to Release Employment Information
1
Candidate Name
2
Work History
3
Employment Verification
Candidate Name
Position Applied For
Consent
I hereby authorize my former/current employer listed below to release information regarding my employment to Victory Home Care Agency for the purpose of verifying my
Work History
Employer Name
Address
Phone
Consent
I understand this information will be used only for employment purposes.
Candidate Signature
Date
MM slash DD slash YYYY
Employment Verification
Dates of Employment
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Job Title
Eligible for Rehire?
Yes
No
Reliability/Punctuality
Excellent
Good
Fair
Poor
Overall Job Performance
Excellent
Good
Fair
Poor
Additional Comments
Completed By (Name & Title)
Signature
Date
MM slash DD slash YYYY
Quick Inquiry
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