PREFERRED PRIVATE CARE
Application Form
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
The following characters cannot be used on this form
(%,&,/,?,>,<,|,{,})
Personal Information
First Name
*
M.I
Last Name
*
Home Phone
*
Cell Phone
*
Cell Phone Provider
Please Select
Alaska Communications
Alltell
ATT
Bell Mobility
Bluegrass Cellular
Boost
C Spire
Cincinnati Bell
Cingular
Cricket
Fido
Freedom Mobile
GCI Wireless
Helio
Koodo Mobile
MetroPCS
My Family Mobile
Nextel
Qwest
Rogers
Rogers Wireless
Simple Mobile 1
Simple Mobile 2
Solo
SouthernLINC
Sprint
Straight Talk
T-Mobile
Telus
US Cellular
Verizon
Virgin
Virgin Canada
Wind
Xfinity
Work Phone
Email
*
How did you hear about us?
Career Source
Caregiver Referral
Client
Co-Worker
Craigslist
Fenn Center Job Fair
Friend
Indeed
Medical Training Center
MyCNAJobs
Paramount Training
School
Walk In
Website
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 registration, or, if registered, shall be grounds for dismissal.
Date
Print your name
Draw It
Clear