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About
Services
For Caregivers
Testimonials
Contact
Job Application
Please apply by filling out the details below.
Page
1
of 12
About You
Name
First
Last
Positions available
*
Please select
Homemaker
Companion
Personal-care
Live-in
Preferred work type
*
Please select
Full-time
Part-time
Overnight
Live-in Weekdays (Mon-Fri)
Live-in Weekends (Fri-Mon)
Gender
*
Male
Female
Date of Birth
*
Language you speak
*
Social Security Number
Please select
Yes
No
Are you eligible to work in USA
Next
Address
Street
Please select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip code
City
City
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Contact
How would you like to be contacted?
Home / office
Mobile / cell phone
Email
Mobile Tel
*
Home Tel
Email address
*
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Next
Education
High School Grad
*
Yes
No
Did you receive a GED
*
Yes
No
College Grad
*
Yes
No
Do you currently have a CNA/PCA/HHA license?
State Level
Date
Expiry Date
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Next
Employment
Are you currently employed?
*
Yes
No
Other
Name of current employer
From
To
Job title
Address
Phone
Email address
Please explain
Were you employed before this job?
*
Yes
No
Other
Name of previous employer
From
To
Job title
Address
Phone
Email address
Please explain
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Next
Restrictions
Select any work limitations that you may have :
Hearing
Speech
Lifting
Health
Physical
Emotional
Type here to briefly describe
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Availability for Work
Select days available for work
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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Client Types and Work Duties
Clients Not Willing/Able to Work With
Dementias/Alzheimers
Behavioral Disorders
Mentally challenged
Smokers
Females
Males
Pets
Elderly (over 65)
Children
HIV Positive/Aids
Physical Disabilities
Duties Not Willing/Able to Perform
Bathing
Lifting / Transferring clients
Grooming
Oral Care
Dressing
Bowel Care
Bladder Care
Feeding
Ambulation
Using Hoyer or other lifts for purposes of transfer
Housekeeping
Laundry
Meal Preparation
Shopping
Transportation
Medication Reminding
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Next
Transportation
Transport Type
Private vehicle
Bus
Train
Make and model
Valid driver license number
Year of vehicle
Policy Number
State issue
Expiry date
Auto insurance company
Date
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Next
Transporting Clients
Are you willing to transport clients in your private vehicle?
*
Yes
No
Do you have adequate vehicle insurance?
*
Yes
No
Are you willing to drive a client’s vehicle?
*
Yes
No
Are you willing to escort a client in their own vehicle?
*
Yes
No
Are you willing to escort a client on public transportation?
*
Yes
No
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Next
Investigations
Have you ever been convicted of a crime in a state court or federal court in any state. If “yes”, please explain
*
Yes
No
Please explain
Have you ever been investigated for abuse, neglect or domestic violence? If “yes”, explain:
*
Yes
No
Please explain
Were you subject to any decision imposing disciplinary action by a licensing agency in any state, or the District of Columbia. If “yes” please explain.
*
Yes
No
Please explain
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Next
Employment Application
I certify that I have read and understand this application. The answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. Additionally, any prospective employee who makes a false written statement regarding prior criminal convictions or disciplinary action can be guilty of a class A misdemeanor. I authorize former employers, references and any other individual/organizations to provide information to Affordable Professional Caregivers (APC) and I hereby release and discharge any of the above and APC from any liability of any kind or nature. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and completion of a background check. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.
First Name and Last name
*
Todays Date
*
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