JOB/EMPLOYMENT APPLICATION for a HOME CARE ASSISTANT

Advocates for the Independent


Personal Information


NAME

ADDRESS

PHONE

Electronic

Date of Birth

SSN

Gender

Language

Emergency Contact

Education

Formal

Informal

Restrictions


Work Limitations
List any work limitations that you may have and briefly describe:

Availability for Work

Indicate Days and List Hours Available for Work

Client Types and Work Duties


Type of Position(s) Preferred

Clients Not Willing/Able to Work With

Duties Not Willing/Able to Perform

Experience

Assignment Location

Transportation


Type

Driver's License

Transporting Clients

Abuse Investigation


Reference Information


Work Related #1 (Last Position)

Work Related #2 (2nd Last Position)

Work Related #3 (3rd Last Position)

Personal #1

Personal #2


I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained in this application, as required. Additionally, I authorize former employers, references and any other individual/organizations to provide information to Advocates for the Independent and I hereby release and discharge any of the above and Advocates for the Independent from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary.

I agree to a physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with the Agency. I also understand that employment, for certain positions, may be conditional upon successful completion of a substance abuse screening test ,if part of the Agency’s pre-employment policy.

I understand that, if hired, I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States.



You can also Download Our Application here and email it to our office.