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Name
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Date of Birth
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Address
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City
State
Zip Code
Telephone Number
Email address
Can you be reached by email?
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Are you at least 18 years of Age?
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Which position are you applying for?
What is your expected hourly wage?
Able to meet the physical and mental demands required to perform specific tasks of the consumer; agree to maintain confidentiality; be emotionally mature and dependable; able to handle emergency situations; and not be the consumer’s spouse?
Yes
No
Have you lived in ILLINOIS for the past 5 years?
Yes
No
(if no please list the city and state)
(if no please list the city and state)
Do you smoke?
Yes
No
Background: A background screening must be performed prior to the first day of employment. Have you been charged with an offense other than minor traffic violation? Yes or No Please disclose all criminal convictions, finding of guilty, plea of guilt and pleas of nolo contendere or provide a statement there is no record of such on my background. Failure to disclose of any criminal information is a violation of the law. If this does not apply please state N/A.
Have you ever been convicted of any criminal convictions, finding guilty or plea of guilty?
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No
Are you willing to submit to a pre-employment criminal record check?
Yes
No
If no please explain
Yes or NO Please disclosed all criminal convictions (charges and date)
Do you have a skilled license?
Yes
No
Do you have a Valid Driver’s license?
Yes
No
If Yes type
Do you have experience working with a person with physical/cognitive disabilities?
Yes
No
(if yes please explain)
Have you served in the military?
Yes
No
Which Branch?
Date of discharge
MM slash DD slash YYYY
Do you have any alias named or Social Security Numbers?
Yes
No
If yes please disclose
Do you agree to a pre-employment record check?
Yes
No
If No why?
Do you consent to a close record check?
Yes
No
If No why?
Preferences and Availability
Do you prefer working with
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Female
What days and times are you available?
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Please circle the following duties that you are willing to perform on a daily basis
Dressing
Laundry
Bathing
Cleaning
Feeding
Transfer
Errands
Meal Preparation
Shopping
Toileting
Employment History
1. Company Name
Supervisor Name
Start Date
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End Date
MM slash DD slash YYYY
Position
May we contact
Yes
No
Eligible for rehire
Yes
No
Duties
Reason for leaving
2. Company Name
Supervisor Name
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Position
May we contact
Yes
No
Eligible for rehire
Yes
No
Duties
Reason for leaving
3. Company Name
Supervisor Name
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY
Position
May we contact
Yes
No
Eligible for rehire
Yes
No
Duties
Reason for leaving
Consent
I certify that the answers given are true and complete to the best of my knowledge and I hereby grant permission for background screening in accordance with the Illinois Department of Public Health Criminal History Records Information (CHRI)Check to be performed for employment purposes.
Applicant Signature
Date
MM slash DD slash YYYY
Consent
I certify that the facts contained in this application are true and complete to the best of my knowledge and I understand that if employed, falsified statement on this application shall be grounds for termination/ dismissal. I authorized investigation of all statement contained herein and the reference and employers listed to give to you and all information concerning my previous employment and any pertinent information they have, personal or otherwise and released Caring Hands Home Nursing Care Inc. For liability for any damage that may results from utilization or such information.
Consent
I also understand and agree that no representative of Caring Hands Home Nursing Care Inc has any authority to enter into an agreement for employment for any specified period, or to make any agreement contrary to the foregoing, unless it is writing and signed by an authorized agency representative.
Applicant Signature
Date
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