CaringTree Senior Care- Employment Application


	Companionship and care in the most comforting place of all, your home. Call today (440) 386-4660

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Thank you for your interest in joining the CaringTree team. Please complete the application below and hit the submit button. We will be in touch with you shortly after we receive your completed application.

PLEASE COMPLETE ALL QUESTIONS

NOTE: CaringTree Senior Care Requires a Criminal Background Check as Condition of Employment. Applicants WILL be tested for illegal drugs.

* = Required

*Last Name

*First Name

Middle Initial

Date

*Address

*City

*State

*Zip

*Phone

SSN -
To be provided at interview

DOB -
To be provided at interview.
Must be 18 years of age to apply.

*Email address

Please indicate the days and times you are available to work:

Work anytime?	Thursday (From - To)
Monday (From - To)	Friday (From - To)
Tuesday (From - To)	Saturday (From - To)
Wednesday (From - To)	Sunday (From - To)

Position applied for

Applied here before?

*Hourly range desired

*How many hours can you work weekly?

Are you available
to work nights?

Are you available
to work weekends?

*Would you consider live-in?

*Employment desired

*Are you legally authorized
to work in this country?

*When are you available to start work?

*Where did you hear about us?

Years of care giving experience:

TYPE OF SCHOOL	NAME OF SCHOOL	CITY	STATE	YEARS COMPLETED	DEGREE	YEAR GRADUATED
High School
College
Bus. or Trade School
Professional School

*Have you ever been convicted of a crime?

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation (A conviction will not necessarily result in the denial of employment):

*Have you ever worked under a different name?

If YES, what was it and what was the reason?

Do you have any relatives or friends that work for CaringTree Senior Care?

If YES, what is their name?

In Case of Emergency, Please Contact:

*Name		*Relation
*Phone		Business Phone

*Do you have a driver's license?

*Do you have auto insurance?

*Do you have a car?

If NO, how would you get to work?

Drivers License Number -
To be provided at interview

State of Issue

Expiration Date
- -

*Have you had any accidents
during the past 3 years?

How many?

*Have you had any moving violations
during the past 3 years?

How many?

List two references. DO NOT LIST relatives.

*Name	*Name
Relation	Relation
*Company	*Company
Address	Address

City	City
State	State
Zip	Zip
*Telephone where person can be reached 9a – 5p	*Telephone where person can be reached 9a – 5p

*An application form sometimes makes it difficult to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications to be a . Please note any experience with caregiving professionally, for your parents, spouse, children or friends.

*Why do you enjoy caregiving?

Please describe some of your volunteer work:

Please list any certifications you currently possess:

Certified Nursing Assistant	Certified Medical Technician
Certified Medicine Aide	CPR Certified
Geriatric Nursing Assistant	First Aid Certification
Certified Home Health Aide	Personal Support Worker

Please list at least two of your work experiences for the past five years beginning with your most recent job held. If you were self-employed, give company name.

Current or Most Recent Employer Information

*Employer Name	City	*Name of last supervisor
Address	State	*Phone number
	Zip	*Your last job title

Employment Dates	Pay or Salary
From - -	*Start
To - -	*Final

*Reason for leaving (be specific):

*List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:

*May we contact your present employer?

If NO, Please Explain Why and Please Provide Us With Another Work Reference:

Additional Employer Information

*Employer Name	City	*Name of last supervisor
Address	State	*Phone number
	Zip	*Your last job title

Employment Dates	Pay or Salary
From - -	*Start
To - -	*Final

*Reason for leaving (be specific):

*List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked here:

*May we contact this employer?

If NO, Please Explain Why and Please Provide Us With Another Work Reference:

How would you rate yourself on your experience with the following aspects of caregiving?
1 = No Experience 2 = Some Experience 3 = Good Experience 4 = Excellent Experience

Companionship	Dementia/Alzheimer's Care	Grocery Shopping
Bathing/Showering	Clean Bathrooms	Cooking/Meal Prep
Dressing/Grooming	Clean Kitchen	Driving
Incontinence Care	Mechanical Lift	Medication Reminders
Transferring	Laundry

Comments

I certify that I have read and understand the application note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information 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 any 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. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

Phone: (440) 386-4660 ~ E-mail: joe.orlando@caringtreeinc.com

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Driving Information

Reference Information

Work Experience

Skill Information

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