Guardian Angel Senior Services Inc.

Application Form
We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, medical condition, national origin, or marital status.
The following characters cannot be used on this form (%,&,+,/,?,>,<,|,{,})
Personal Information
First Name
  *
Address 1 *
M.I
 
Address 2
Last Name
  *
City *
Home Phone
  *
State/Prov *
Cell Phone
    *
Postal Code *
Cell Phone Provider
 
Position Applying For*
Work Phone
 
SSN* 
E-Mail
  * 
Confirm SSN
How long at this address?
  *
Have you ever been convicted of a crime?
If yes, explain the nature and dates of the conviction(s)

What do you like most about working with the elderly, disabled, or convalescing client?

What do you find most challenging in this type of work?


Emergency Contact
Name
  *
Phone
  *
Alt PhoneRelationship
Address City
StateZip

Transportation
Do you have a car Driver’s License #
If you don’t have a car how would you get to work? Expiration:

Availability
How many hours can you work weekly? Are you available to work nights? Are you legally authorized to work in this country?

Would you consider live-in?Employment Desired Are you available to work weekends?
Available to Start Date  
Are there any times you are not available to work?  

Education

Type
Name City State/Prov Year Completed Degree Major

High School

College

Bus.or Trade School

Professional School

Certifications and Professional Licenses
addlicense numberexpiration date
Delte

Skills

Please indicate whether you have assisted with or performed the following tasks
CompanionshipDressing/Grooming
Meal PreparationTransferring
Light Housekeeping Incontinence Care
Bathing/ShoweringDementia / Alzheimers
Additional Skills


Employment History (list most recent first)
Company From To
Job Title Reason Left
Duties

Supervisor Phone May we contact



Company From To
Job Title Reason Left
Duties

Supervisor Phone May we contact



Company From To
Job Title Reason Left
Duties

Supervisor Phone May we contact

References

Name

Relationship

Years Known

Phone



Certification and Release Section


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