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Application
Name
*
First
Last
Email
*
Present Address (Street, City, State, Zip)
*
Phone Number
*
Social Security Number or Tax ID
Vehicle (Year, Make)
*
Driver’s License Number
Do You Have A Current Fingerprint Clearance Card?
Yes
No
Date Available
*
Available for
*
Part time (20-30 hours per week)
Full time (31-40 hours per week)
Live in Care (24 hours shifts)
Days Available to Work
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Education (Check all completed degrees/diplomas/certifications)
Certified Caregiver
Certified Nursing Assistant
Licensed Practical Nurse
Registered Nurse
Masters of Science in Nursing
Other Associates
Other Bachelors
Other Masters
Other Doctorate
Discuss in detail any relevant education completed
Reference 1
Please provide name, relationship, telephone number, and years known.
Reference 2
Please provide name, relationship, telephone number, and years known.
Reference 3
Please provide name, relationship, telephone number, and years known.
May we contact the references provided above?
*
Yes
No
Present/Last Employer
*
Employer's contact information
*
Employer's Address
Position Title
*
Summary of Duties
Dates Employed
Reason for Leaving
May we contact the employer provided above?
*
Yes
No
Employer 2
*
Employer's contact information
*
Employer's Address
Position Title
*
Summary of Duties
Dates Employed
Reason for Leaving
May we contact the employer provided above?
*
Yes
No
Employer 3
*
Employer's contact information
*
Employer's Address
Position Title
*
Summary of Duties
Dates Employed
Reason for Leaving
May we contact the employer provided above?
*
Yes
No
Describe any experience you have had with seniors and special needs populations.
Describe any personal, volunteer or work related experiences that will help you in this position
Have you had a TB test in the last 3 years?
Yes
No
Have you ever been convicted of a crime besides a minor traffic ticket?
Yes
No
If you answered yes to the above question, please explain the crime, conviction, and date.
Resume
If you have a resume that you would like to share, please paste the content into this box.
Are you legally authorized to work in the United States?
*
Yes
No
By clicking agree, I certify this information to be true and agree to allow Helpful Hands Home Care to perform a criminal history background check, at their leisure, and I give permission for them to check my references.
*
Agree
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