Preferred Private Care

Application Form

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Personal Information
First Name
  *
M.I
Last Name
  *
Home Phone
  *
Cell Phone
    *
Cell Phone Provider
 
Work Phone
Email
  * 
Address 1
*
Address 2
City
*
State/Prov
*
Postal Code
*
Position Applying For
*
SSN
* 
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
  *
Alt Phone
Address
State
Phone
  *
Relationship
City
Zip
Transportation
Do you have a car?
If you don’t have a car how would you get to work?
Driver’s License #
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
High School
Name
City
State/Prov
Year Completed
Degree
Major
College
Name
City
State/Prov
Year Completed
Degree
Major
Bus.or Trade School
Name
City
State/Prov
Year Completed
Degree
Major
Professional School
Name
City
State/Prov
Year Completed
Degree
Major
Certifications and Professional Licenses
addLicense numberExpiration date
Delte
Skills
Please indicate whether you have assisted with or performed the following tasks
Companionship
Meal Preparation
Light Housekeeping
Bathing/Showering
Dressing/Grooming
Transferring
Incontinence Care
Dementia / Alzheimers
Additional Skills
Employment History (list most recent first)
Company
From
To
Job Title
Reason Left
Duties
Supervisor
Phone
May we contact you?
Company
From
To
Job Title
Reason Left
Duties
Supervisor
Phone
May we contact you?
Company
From
To
Job Title
Reason Left
Duties
Supervisor
Phone
May we contact you?
References
Reference 1
Name
Relationship
Years Known
Phone
Reference 2
Name
Relationship
Years Known
Phone
Reference 3
Name
Relationship
Years Known
Phone
Reference 4
Name
Relationship
Years Known
Phone
Certification and Release Section
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Date