J&M Homecare Services, LLC dba Visiting Angels
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.
Please Enter First Name
Please Enter LastName
Please Enter Home Phone Number
Please Enter Cell Phone Number
Please Enter E-mail Address
Please Enter Address1
Please Enter City
Please Enter State/Prov
Please Enter Postal Code
Please Enter the Position Applying For
Please Enter SSN
Please Enter How long at this address
Please Enter Contact Name
Please Enter Contact Phone
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Personal Information
First Name
*
M.I
Last Name
*
Home Phone
*
Cell Phone
*
Cell Phone Provider
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Work Phone
Email
*
How did you hear about us?
11/12/19 MyCNA Job Fair - EDD
Barrett Job Fair 4.25.18
Blanca Nieto
Cal Jobs
CareListings
CG Referral
College of Marin
College of Marin 04/25/18
Craigslist Ad
Darian Smolowe
Denis H.
East Bay Works Event 4/4/18
EB Works San Pablo 4/11/18
Facebook
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Glassdoor
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Indeed Ad
Indeed Search
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Jazz- MyJobHelper
Jeffrey Anyeneh
Job Fair 11/4/20
Job Fair Oak 9-17-19
Los Medanos Job Fair 5/1/18
Manteca Library 6.16.17
Marin CDC 5/17/18
Marin City Community Job& Resource Fair
Marin Community Job Fair 6/7/18
Marin General Hospital
Modesto JC 9-20-17
MT Tamalpais Adult School
My CNA Job Fair - EDD 11.12.19.
MyCNA Job Fair 11/12/20
MyCNA Job Fair 11/5/20
MyCNA Job Fair 6/21/18
MyCNAJobs Interview Booking
MyCNAjobs Search
Neighbor
Novato Adult School
Oak Park SR CTR 2/18/2020
Oak Park Sr Ctr Job Fair 2/18/20
PETRA
Pittsburg Adult School
Richmond Works
Robyn Diamond
rosa aguliar
Rosemary Lukholo
San Rafael Community Job Fair
SR Open House
Stockton Library 10-3-17
Stockton Worknet Center
Tamlapais Adult School
Tanaqua Adams
Tracy Worknet Center
Unitek hiring event 9-22-17
VA Admin Employee
VA Corporate
Vallejo Job Fair - MyCNA - 10.11.17
Zip Recruiter
Zip Recruiter-Resume Database Search
Other
Address 1
*
Address 2
City
*
State/Prov
*
Postal Code
*
Position Applying For
*
SSN
*
(NNN-NN-NNNN)
Confirm SSN
How long at this address ?
*
Have you ever been convicted of a crime?
No
Yes
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?
No
Yes
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?
Yes
No
SomeTimes
Are you legally authorized to work in this country?
Yes
No
Would you consider live-in?
Yes
No
Employment Desired
Full Time
Part Time
Full or Part Time
Are you available to work weekends?
Yes
No
Available to Start Date
Are there any times you are not available to work?
Education
High School
Name
City
State/Prov
Level Completed
Degree
Major
College
Name
City
State/Prov
Degree
Major
Bus.or Trade School
Name
City
State/Prov
Degree
Major
Professional School
Name
City
State/Prov
Degree
Major
Certifications and Professional Licenses
License number
Expiration date
Attributes
Please indicate whether you have assisted with or performed the following tasks
Companionship
Yes
No
Meal Preparation
Yes
No
Light Housekeeping
Yes
No
Bathing/Showering
Yes
No
Dressing/Grooming
Yes
No
Transferring
Yes
No
Incontinence Care
Yes
No
Dementia / Alzheimers
Yes
No
Additional Skills
Employment History (list most recent first)
Company
From
To
Job Title
Reason Left
Duties
Supervisor
Phone
May we contact?
Yes
No
Company
From
To
Job Title
Reason Left
Duties
Supervisor
Phone
May we contact?
Yes
No
Company
From
To
Job Title
Reason Left
Duties
Supervisor
Phone
May we contact?
Yes
No
Professional References (manager, supervisor, etc.)
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
I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that the withholding, misrepresentation or falsification of information shall be grounds to refuse employment, or, if employed, shall be grounds for dismissal.
Date
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Clear