Employment Interest Form Caregiver Application Contact Info First Name * Last Name * Phone * Email Address * Best Time to Call * Morning Afternoon Evening Address * City * State 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 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? * Website Internet Job Board Family/Friend Newspaper Facebook 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? No Yes 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.