Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Position applying for *Select belowCaregiverCNA/CaregiverAdministrative AssistantSchedulerSupervisor/CaregiverHow did you hear about us? Who referred you? *An employee of I Care At HomeSocial MediaIndeedFacebookOtherIf referred by an employee of I Care At Home or Other please provide us their name belowYour Name *FirstLastStreet Address: *City *State *Zip Code: *Phone: *Email: *Date of birth: *Desired hourly wage$ *Are you a citizen of the United Stated? *YesNoIf no, are you authorized to work in the U.S.? *YesNoHave you ever been convicted of a felony? *YesNoIf yes, explain:Do you have a reliable vehicle? *YesNoGive me an example of a reason to be late to work: *What days of the week are you available to work? Check all that applySundayMondayTuesdayWednesdayThursdayFridaySaturdayWhat shifts are you available to work? Check all that applyDaysEveningsNightsEducation *High SchoolGEDCollegeDid you graduate *YesNoAttendingPROFESSIONAL REFERENCE 1 *Full NameTitle: *Company: *Phone: *PROFESSIONAL REFERENCE 2 *Full NameTitle: *Company: *Phone: *Previous Employment: *CompanyPhone: *Address: *Supervisor: *Job Title: *Starting Salary$ *Ending Salary$ *Responsibilities: *Start Date: *End Date: *Reason For Leaving: *May we contact your former supervisor for a reference? *yesnoPerformance audit Selected Value: 0 Rate yourself on a scale from 1 to 10 with 10 being the best on how you think you performed as an employee with this company. Attendance, team player etc…Previous Employment 2 *Company:Phone: *Address: *Supervisor: *Job Title: *Starting Salary$ *Ending Salary$ *Responsibilities: *Start Date: *End Date: *Reason for leaving: *May we contact your former supervisor for a reference? *YesNoPerformance audit (copy) Selected Value: 0 Rate yourself on a scale from 1 to 10 with 10 being the best on how you think you performed as an employee with this company. Attendance, team player etc…Name *FirstLastI certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.Submit
