Employment Form
 
 
Background Information
Name
Address
City
Zip Code
State
DOB
Cell Phone
Home Phone
Email
Do you own a car?
Yes      No
Do you have a driver license?
Yes      No
Education
Graduation Date
Location
Name of High School
Graduation Date
Location
Major
Name of College
Graduation Date
Location
CNA Training School
Are you a Medication Aide?
Are you trained in First Aid?
Are you trained in CPR?
Yes      No
Yes      No
Yes      No
Work History
Include the name of employer, address,phone number, name of supervisor,  dates of
employment, salary, job title,the reason for leaving and list the specific duties performed.
May we contact your previous employers?
References
List three references other then relatives or employers. Include name, work position,  
phone number and years of acquaintance
Job Preference
Why are you suitable for a
caregiver/nanny position with us?
What position are you applying for?  (select all that apply)
Elder Care
Mother's Helper
Errands
Work Availability (select all that apply)
Part-Time
Full-Time
Live-Out
Live-In
Weekends
Days
Evenings
Over-Nights
Do you any special skills that you can share with
children or seniors? (language, art, craft, etc.)
What are your views/methods
of disciplining children?
Health Information
Do you have any mental, physical  limitations? If yes explain
Are you updated on your shoots?
Do you smoke?
Yes      No
Yes      No
Married
Single
Person to contact in case of emergency
with phone number
Have you ever been convicted of a crime? Explain
How were you referred to Loving Home Care?
friend, newspaper, etc. state the name
Additional Comments
Today's Date
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Name
Email Address
Zip Code