Employment Interest Form Caregiver Application Contact Info First Name * Last Name * Phone * Email Address * Best Time to Call * Morning Afternoon Evening Address * City * State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Personal Information Education Level * High School/GED Some College College Graduate Are you Registered with the California Home Care Services Bureau? * Yes No Yes, But it is expiredYes, But it is expired Are you currently registered with the Home Care Services Bureau as a Home Care Aid? If Yes, Please Note your Home Care Aid Number Here Date Available to Start Working * Please describe your desired work schedule: * How did you hear about Safe at Home Senior Care? * WebsiteInternet Job BoardFamily/FriendNewspaperFacebook Have you ever been convicted of a criminal offense? * Yes No If yes, state the nature of the crime(s), when and where convicted, and the disposition of the case. (Note: No applicated will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however be considered.) * Do you have a Valid Califonia Drivers License? Yes No Do you own a vehicle? * Yes No Can you provider proof of insurance? Yes No Have you ever applied or worked for Safe at Home Senior Care? * Yes No If yes, when? Do you have experience working with Seniors? NoYes Please describe your experience working with seniors: Employment History Name of Company * Position * Length of Employment * Contact Information * Name of Company 2 * Position 2 * Length of Employment 2 * Contact Information 2 * If you are human, leave this field blank. Δ
