Caregiver Application - EXACT HOME HELP CARE

Exact Home Help Care Job Application

Instructions: Please enter your information. Answer all questions. All information is stored on a secure server.

Personal Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone *

Email *

Eligibility

Have you ever been convicted of a FELONY after 1996? *

Yes

If you answer YES to this question, please stop the application process.

Are you eligible to work in the United States? *

Yes

If you are under age 18, do you have an employment/age certificate? *

Yes

If yes, please explain:

Position & Availability

Position(s) *

Caregiver (Non-Medical)

Days Available * (Select all that apply)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Any Day

Hours Available *

Graveyard

For specific Day/Hour availability, please enter information below:

Please share what cities you prefer to work in *

What date are you available to start work? *

Education & Qualifications

EDUCATION: *

Skills and Qualifications: *

CPR Card Expire Date

First Aide Expire Date

Date of your last TB Test

Please check which of the following skills you can perform: *

Client Transfers

Meal Preparation

Client Showers

Light Housekeeping

Hoyer Lift

Brief Changes

Employment History

Employer: *

Address

Phone

Position/Title: *

Start Date *

End Date *

Salary/Hourly Wage *

Reason for Leaving: *

May We Contact Your Present Employer? *

Yes

References

Please provide three professional references

Reference 1 (Name/Title, Address, Phone) *

Reference 2 (Name/Title, Address, Phone) *

Reference 3 (Name/Title, Address, Phone) *

Documents

Don't have a scanner? You can download "Scan to PDF Free" app to convert documents to PDF.

Resume Upload

Additional Documents You can select multiple files. Accepted formats: PDF, DOC, DOCX

Authorization

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of Exact Home Help Care has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized Exact Home Help Care representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws.

Exact Home Help Care is an Equal Employment Opportunity (EEO) employer and does not discriminate on the basis of race, color, national origin, religion, gender, age, veteran status, political affiliation, sexual orientation, marital status or disability (in compliance with the Americans with Disabilities Act) with respect to employment opportunities.

Employee Signature (Type full name) *

Date *

Where did you find our Employment Ad? *