Home Care Service Worker Job Application

Home Service Worker Job Application

Home Care Angels is an equal opportunity Home Service Agency. We consider applicants for referral without regard to race, color, religion, sex, national origin, age, marital status or sexual orientation, veteran status, the presence of a medical condition or disability unrelated to the ability to perform with or without a reasonable accommodation, or any other legally protected status under applicable law.

Today's Date

First Name *

Last Name *

Mobile Phone Number *

Home Phone Number

Would you like to receive text messages?

Yes

No

Email

Address

How were you referred to us?

Home Care Angels is an equal opportunity Home Service Agency. We consider applicants for referral without regard to race, color, religion, sex, national origin, age, marital status or sexual orientation, veteran status, the presence of a medical condition or disability unrelated to the ability to perform with or without a reasonable accommodation, or any other legally protected status under applicable law.

Employment Information

Have you ever been a caregiver before?

Yes

No

If yes, for how long?

Fingerprints Date:

Shift Preference:

Live-in

Come and Go

Time Preference:

Full-time

Part-time

Date available to begin work:

Are you willing to work with the following situations:

Smoking:

Yes

No

Pets:

Yes

No

Family:

Yes

No

Do you possess a valid/current driver’s license?

Yes

No

Are you willing to take a job out of your area? Suburbs or City?

Yes

No

Do you drive your own car?

Yes

No

If no, do you have transportation to get to the client’s location?

Yes

No