Caregivers and Homemakers Application

Leave blank

Application

Applicant Information

NAME

First Name Last Name Email

DRIVER'S LICENSE

License Received

Yes No

Number State

MAILING ADDRESS

Line 1 Line 2

City

State

Zip Code

OTHER INFORMATION

Home Phone

Mobile Phone

Social Security Number Birth Date

Experience

PREVIOUS CAREGIVER EXPERIENCE #1

Organization Contact Person Telephone Dates Worked May We Contact?

Yes No

PREVIOUS CAREGIVER EXPERIENCE #2

Organization Contact Person Telephone Dates Worked May We Contact?

Yes No

PREVIOUS CAREGIVER EXPERIENCE #3

Organization Contact Person Telephone Dates Worked May We Contact?

Yes No

PREVIOUS CAREGIVER EXPERIENCE #4

Organization Contact Person Telephone Dates Worked May We Contact?

Yes No

Professional References (do not include family or friends)

REFERENCE #1

Contact Person Position/Title Telephone Dates Known

REFERENCE #2

Contact Person Position/Title Telephone Dates Known

REFERENCE #3

Contact Person Position/Title Telephone Dates Known

Education

COLLEGE #1

Name Location Major Graduate?

Yes No

End Date

COLLEGE #2

Name Location Major Graduate?

Yes No

End Date

COLLEGE #3

Name Location Major Graduate?

Yes No

End Date

HIGH SCHOOL

Name Location Graduate?

Yes No

End Date

General Availability

Are you available for all hours?

Yes No

Please list your availability below:

Mon:

Tues:

Wed:

Thurs:

Fri:

Sat:

Sun:

LIVE-INS
Being a Live-In means several consecutive days of care where the Caregiver stays at the care recipient's home for the entire duration of the days.

Are you interested in providing Live-In care?

Yes No

If yes, choose maximum # of days

Skills and Preferences

Specialized Training

Additional Questions

Do you have access to reliable transportation?

Yes No

Are you a smoker?

Yes No

If yes, how many per day?

How did you hear about us?Tell us about recent caregiving experiences.Why do you want to be a caregiver with us?

Emergency Contact Information

EMERGENCY CONTACT #1

Name Relationship

Phone

Type

Phone Alt

Type

EMERGENCY CONTACT #2

Name Relationship

Phone

Type

Phone Alt

Type

EMERGENCY CONTACT #3

Name Relationship

Phone

Type

Phone Alt

Type

CERTIFICATION AND RELEASE

I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions, or misrepresentation of facts will result in rejection from this application and/or discharge at any time during the employment period. I authorize LANDMARK Homecare LLC to verify any and all information contained within this application, 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 such said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment.

Agree?

Yes No

RESTRICTIVE COVENANT

I acknowledge that all information I have provided in this application is true, accurate, and complete to the best of my knowledge. I understand that any false, misleading, or omitted information may result in the rejection of my application or, if discovered after employment, may result in disciplinary action, including termination of employment.

Agree?

Yes No

Applicant Signature

Sign here

Please provide your signature.