Section 1 General Information
Number
Questions
1
Positioning Applying For?
2
Who referred you to this site or how did you hear about us?
3
How long have you lived at your current address?
4
Are you 21 years or older?
Yes
No
5
Have you ever applied for a position at Confident Care before?
Yes
No
6
We do not permit smoking while on duty. Are you willing to comply?
Yes
No
7
Up to 50 lbs. of lifting several times a day is an essential function of care giving. Are you willing and able to comply with this requirement?
Yes
No
8
Confident Care does not tolerate drug use by employees before or during work. Are you willing to comply?
Yes
No
9
Would you consent to pre-employment background checks, verification of your work history and a pre-employment drug test?
Yes
No
10
Do you have reliable transportation to and from work during all shift hours?
Yes
No
11
Can you provide documentation of a driver's license and auto insurance?
Yes
No
12
Do you have more than two moving violations in the last 3 years?
Yes
No
13
Have you ever worked under another name?
Yes
No
14
Please list other name:
15
How many years of care giving experience do you have?
16
How many years of experience do you have working in "Home Care"?
17
Do you have experience working with clients that have Dementia or Alzheimer’s?
Yes
No
18
Are you capable of reading, writing, and understanding English as part of performing job related duties?
Yes
No
19
If you speak any languages other than English, please list:
20
What is the minimum amount you need to earn?
21
If offered a position with Confident Care, how long would you plan to remain with us?
22
Why are you applying for a position with us?
23
Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other that has not been annulled, expunged or sealed by the court?
Yes
No
24
If yes, please explain:
SECTION 2-CHARACTERSTICS
1
How many jobs have you had in the last year?
2
How many jobs have you had in the last year?
3
Have you ever quit a job without giving two-weeks notice?
Yes
No
4
Have you ever been fired or asked to resign from a job?
Yes
No
5
If Yes, Please explain?
6
Have you ever ignored company policy because most other employees ignored it, too?
Yes
No
7
Have you ever taken cash or items from an employer or client because you did not think you had been paid enough?
Yes
No
8
Is it okay to borrow something from work/client with out permission as long as you return it?
Yes
No
9
Have you been recently blamed at work for something that was not your fault?
Yes
No
10
Have you ever had a problem with a co-worker at a previous job?
Yes
No
11
Have you been in an argument with a client or client's family in the past?
Yes
No
12
Do you believe an employee should be warned three times about missing work before action is taken?
Yes
No
13
How often do you lose your temper?
14
On average, how often are you late for work?
15
How many days were you absent from work during
16
Do you consider yourself as having strong people skills?
Yes
No
17
Would clients say you go out of your way to help them?
Yes
No
18
Do you think most accidents and injuries can be avoided?
Yes
No
19
Do you enjoy interacting with others during the day?
Yes
No
SECTION 3 - AVAILABILITY
1
When would you be available to start?
2
Are you giving your current employer two weeks notice?
Yes
No
3
Do you have any schedule obligations (e.g., annual trips, vacations, weddings, reserve duty, or holidays) coming up that we need to know about?
Yes
No
If Yes, Explain:
5
What commitments do you have, or do you anticipate, that may affect your schedule?
Yes
No
6
Would you be willing to work flexible hours (including weekends)?
Yes
No
7
Are you willing to work holidays?
Yes
No
8
Are you willing and able to work 12 hour shifts?
Yes
No
9
Are you willing and able to work double shifts?
Yes
No
10
Are you willing to work day shifts?
Yes
No
If yes, which days?
11
Are you available to work evening shifts?
Yes
No
If so, which evenings?
12
Are you available to work overnight shifts?
Yes
No
If yes, which overnights?
13
Are you available to work Live-In shifts?
Yes
No
If yes, what days?
14
What days and times of the day are you NOT available to work?
SECTION 4 – EMPLOYMENT ELIGIBILITY
15
Are you a U.S. citizen?
Yes
No
16
If you are not a U.S. Citizen, please indicate VISA type and number.
17
Are you authorized to work in the U.S.?
18
I am authorized to work in the U.S. for any employer.
Yes
No
19
I am authorized to work in the U.S. for my current employer.
Yes
No
20
I require sponsorship to work in the U.S.
Yes
No
21
I do not know my work status
Yes
No
SECTION – 5 EDUCATION
1
Name of High School?
2
Did you graduate?
Yes
No
3
What years did you attend High School (From/To)
4
Additional Education (vocational, undergraduate, etc.)?
5
If yes, please list the name of the school and years attended (From/To)
SECTION 6 – CERTIFICATIONS / LICENSES / CREDENTIALS
1
Do you have a current License in good standing from the state to which you are applying?
Yes
No
2
List current licenses:
4
List current Certificates:
5
Has your License / Certification ever been revoked or suspended?
Yes
No
6
Please list the last date you had a TB Skin Test or Chest X-ray?
7
Have you ever been fingerprinted for a Care giving job?
Yes
No
SECTION 7 – CURRENT / MOST RECENT EMPLOYMENT
1
Current Employer:
2
Address:
3
City:
4
Zip Code:
5
Start Date:
6
End Date:
7
Starting Wage:
8
Hours Worked:
9
Position/Title:
10
Supervisor's Name/Title:
11
Supervisor's Phone:
12
Amount of time lost in the past year (in days) for any reason:
13
Describe Your Responsibilities:
14
Reason for Leaving:
15
What do you like most about where you are working now?
SECTION 8 – NEXT MOST RECENT EMPLOYER
1
Current Employer:
2
Address:
3
City:
4
Zip Code:
5
Start Date:
6
End Date:
7
Starting Wage:
8
Hours Worked:
9
Position/Title:
10
Supervisor's Name/Title:
11
Supervisor's Phone:
12
Amount of time lost in the past year (in days) for any reason:
13
Describe Your Responsibilities:
14
Reason for Leaving:
15
What do you like most about where you are working now?
SECTION 9 – THIRD MOST RECENT EMPLOYER
1
Current Employer:
2
Address:
3
City:
4
Zip Code:
5
Start Date:
6
End Date:
7
Starting Wage:
8
Hours Worked:
9
Position/Title:
10
Supervisor's Name/Title:
11
Supervisor's Phone:
12
Amount of time lost in the past year (in days) for any reason:
13
Describe Your Responsibilities:
14
Reason for Leaving:
15
What do you like most about where you are working now?
SECTION 10 – 1ST PROFESSIONAL REFERENCE (No Friends / Relatives)
1
Name:
2
Company:
3
Phone:
4
Position:
SECTION 11 – 2ND PROFESSIONAL REFERENCE (No Friends / Relatives)
1
Name:
2
Company:
3
Phone:
4
Position:
SECTION 12 – 3RD PROFESSIONAL REFERENCE (No Friends / Relatives)
1
Name:
2
Company:
3
Phone:
4
Position:
SECTION 14 - SIGNATURE
1
By entering my name and today's date below and submitting this form, I am indicating that I am electronically signing this form and have read and understand the content, intent and terms of this application
2
Date of application:
