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Contact Us Today: (770) 977-9111
Fax: (770) 977-9171
info@eldercarecompanions.com
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Caregiver Application Form


Required fields are marked with a *.
PLEASE COMPLETE ALL QUESTIONS
  *Last: *First: Middle:
Name:
       
  Maiden Name: Previous Last Names:
 
       
*Date of Birth:      

  *Street: *City *State *Zip
Current Address:
         
List previous addresses in the past 7 years      
Previous Address:
Previous Address:
Previous Address:
Previous Address:
Previous Address:

Home Phone:      Cell Phone:      Other Phone 

Employment        
Current Employer          
Employer Name: From: To:
Supervisor Phone May we contact:      
Previous Employer          
Employer Name: From: To:
Supervisor Phone May we contact:      
Previous Employer          
Employer Name: From: To:
Supervisor Phone May we contact:      

Position Applied For:
Please Indicate the days and times you are available:
       
Mon. From: To:
Tues. From To:
Wed. From To:
Thu. From To:
Fri. From To:
Sat From To:
Sun. From To:
Type of Schedule Desired:
       
Hav you ever applied here before?
   
If Yes, When?:
Are you available to work nights?
   
Are you available to work weekends?
   
Would you consider live-in?
   
Do you Have a Car?
   
If Yes,
How far will you drive?
Do you Smoke?
   
Can you refrain from smoking while working?
   
Are you Legally permitted to work in the U.S.?
   
When Can you Start?
Where did you hear about us? *Email:

PLEASE CHECK ANY CERTIFICATIONS YOU CURRENTLY HAVE AND COMPLETE INFORMATION:
License Number: Exp. Date:
License Number: Exp. Date:
License Number: Exp. Date:
TB Test Date of Test: Results:
If your TB Test is outdated or have never had one. Would you be willing to take one?    

Education       Graduation
School Name: Certificate/Diploma: Month:
Special Skills Obtained: Year:
School Name: Certificate/Diploma: Month:
Special Skills Obtained: Year:
School Name: Certificate/Diploma: Month:
Special Skills Obtained: Year:

CAN YOU PROVIDE/SUBMIT TO A:
Valid Drivers License?     Valid Vehicle Insurance?    
Background Check?     Valid Social Security Card?    

Have you ever been convicted of a crime?    
If yes, explain number of conviction(s), nature of offense(s), how recently such offense(s) were committed,
sentence(s) imposed, and type(s) of rehabilitation. ( A conviction will not necessarily result in denial of employment):

Are you ok with:
Dogs:             Cats:             Someone who Smokes:    

 
 
 
     

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Eldercare Companions utilizes for extensive background checks on regular basis.

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