Application Form

Personal Information

First Name *

Last Name *

Social Security Number

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - General Information

Date Available? (required)

Job Type? (required)

Please list your availability for Monday (required)

Please list your availability for Tuesday (required)

Please list your availability for Wednesday (required)

Please list your availability for Thursday (required)

Please list your availability for Friday (required)

Please list your availability for Saturday (required)

Please list your availability for Sunday (required)

Can you provide documentation of a driver's license? (required)

Yes No

Can you provide documentation of auto insurance? (required)

Yes No

Driver License Expiration Date: (required)

Auto Insurance Expiration Date:

Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? (required)

Yes No

If yes, please explain.

Car Model, Make, Color & Year (required)

How many miles are you willing to drive? (required)

(Numeric Answer Only)

Will you work with cats? (required)

Yes No

Will you work with dogs? (required)

Yes No

Will you work with a male client? (required)

Yes No

Will you work with a female client? (required)

Yes No

Will you work in the home of a smoker? (required)

Yes No

Section 2 - Employment Verification

Are you a U.S. citizen? (required)

Yes No

If you are not a U.S. citizen, please indicate VISA type and number.

Are you authorized to work in the U.S.? (required)

Hourly Wage Expectations? (required)

(Numeric Answer Only)

How many years of caregiving experience do you have? (required)

(Numeric Answer Only)

Section 3 - Other Training: Certifications/Licenses

Certifications/Licenses (Ex: CNA, MA, CPR):

Explain your caregiving background/experience: (required)

Are you able to perform transfers of a client? (required)

Yes No

Ae you able to use a Hoyer lift? (required)

Yes No

Are you able to change diapers or depends? (required)

Yes No

Will you assist in toileting? (required)

Yes No

Do you have Memory Care Experience? Dementia? Alzheimer's? Memory Loss? (required)

Yes No

Will you assist in bathing? (required)

Yes No

Can you assist with bed bound care? (required)

Yes No

Will you assist with meal preparation? (required)

Yes No

Will you assist in light house keeping? (required)

Yes No

Will you assist with transporation? (required)

Yes No

Will you assist in errands/shopping? (required)

Yes No

Will you assist in medication reminders? (required)

Yes No

Do you have End of Life/ Palliative/ Hospice Care? (required)

Yes No

Will you assist with pet care? (required)

Yes No

Do you have any physical limitations that would prevent you from assisting with the activities of daily living? If yes, please explain: (required)

Do you have any physical limitations that would assist you in performing transfer assistance? If yes, please explain: (required)

Section 4 - Education

Name of High School: (required)

Location of High School: (required)

Did you graduate? (required)

Yes No

Years Attended (From/To): (required)

Additional Education (vocational, undergraduate, etc.)

Yes No

If yes, please list the name of the school and years attended (From/To)

Section 5 - Employment History- The past 7 years must be given

Previous Employer: (required)

Address: (required)

City: (required)

State: (required)

Zip Code: (required)

Start Date: (required)

End Date: (required)

Hours Worked: (required)

Position/Title: (required)

Describe Your Responsibilities: (required)

Supervisor's Name/Title: (required)

Supervisor's Phone: (required)

Reason for Leaving: (required)

May we contact? (required)

Yes No

Section 6 - Employment History- The past 7 years must be given

Previous Employer: (required)

Address: (required)

City: (required)

State: (required)

Zip Code: (required)

Start Date: (required)

End Date: (required)

Hours Worked: (required)

Position/Title: (required)

Describe Your Responsibilities: (required)

Supervisor's Name/Title: (required)

Supervisor's Phone: (required)

Reason for Leaving: (required)

May we contact? (required)

Yes No

Section 7 - Employment History- The past 7 years must be given

Previous Employer: (required)

Address: (required)

City: (required)

State: (required)

Zip Code: (required)

Start Date: (required)

End Date: (required)

Hours Worked: (required)

Position/Title: (required)

Describe Your Responsibilities: (required)

Supervisor's Name/Title: (required)

Supervisor's Phone: (required)

Reason for Leaving: (required)

May we contact? (required)

Section 8 - Personal Reference 1-Not related by blood/marriage

Name: (required)

Years Known (required)

Phone: (required)

Section 9 - Personal Reference 2-Not related by blood/marriage

Name (required)

Years Known (required)

Phone: (required)

Section 10 - Personal Reference 3-Not related by blood/marriage

Name: (required)

Years Known (required)

Phone: (required)

Section 11 - Emergency Contact Information

First Name: (required)

Last Name: (required)

Address:

City:

State:

Zip Code:

Phone 1: (required)

Phone 2:

Relationship: (required)

Section 12 - Acknowledgements

I acknowledge that I have read and understand the statements listed below. (required)

Yes No

I understand to be considered for a position with Faithbridge Caregiver I must meet the hiring criteria. (required)

Yes No

I understand and agree that: Any material misrepresentation or deliberate omission of a fact in my application may result in refusal of or if employed, immediate termination from employment. Although management makes every effort to accommodate individual preference, business needs may at times make the following conditions mandatory: overtime, shift work, rotating work schedule, or a work schedule other than Monday through Friday. (required)

Yes No

I understand and accept these as conditions of my continuing employment. It is my understanding that Faithbridge Caregivers of will make a thorough investigation of my entire work history and may verify all data given in my application for employment, related papers, or oral interviews. I authorize such investigation and the giving and receiving of any information requested by Faithbridge Caregivers and I release from liability any person giving or receiving such information. (required)

Yes No

I agree that my employment is at will and may be terminated by Faithbridge Caregivers or me at any time with or without notice or cause and without liability for wages or salary except such as may have been earned at the date of such termination. I further understand this is an application for employment and that no employment contract is being offered, nor will any result from my employment with Faithbridge Caregivers. I understand that if I am employed, such employment is for no definite period of time and that Faithbridge Caregivers can change wages, benefits, and conditions at any time. (required)

Yes No

I acknowledge that any oral representation or written statements which may have been made to me to the contrary of this paragraph are expressly disavowed and may not be relied upon. (required)

Yes No

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

Faith Bridge Caregivers Application Form

Personal Information

Section 1 - General Information

Section 2 - Employment Verification

Section 3 - Other Training: Certifications/Licenses

Section 4 - Education

Section 5 - Employment History- The past 7 years must be given

Section 6 - Employment History- The past 7 years must be given

Section 7 - Employment History- The past 7 years must be given

Section 8 - Personal Reference 1-Not related by blood/marriage

Section 9 - Personal Reference 2-Not related by blood/marriage

Section 10 - Personal Reference 3-Not related by blood/marriage

Section 11 - Emergency Contact Information

Section 12 - Acknowledgements