Social Security Number:

* What is the best time to call you?:

* How did you learn of our company?:

Ad - NewspaperAd - MagazineSearch Engine - Ask.comSearch Engine - BingSearch Engine - GoogleSearch Engine - MSNSearch Engine - YahooYellow PagesOnline - Super PagesOnline - FacebookConference - Job FairWord of MouthOur WebsiteCraig's ListPostcard from usOther

If referral, by whom were you referred?:

* Name:

* City/State:

* Did you graduate?:

Yes   No

Name:

City/State:

Subject Concentration:

Did you graduate?:

Yes   No

Name:

City/State:

Subject Concentration:

Did you graduate?:

Yes   No

Other Licenses, Certificates, Programs or Degrees:

* Which of the following training do you have that is current?:

CNAHHAFirst AidCPRFood HandlerDementia trainingNone * Hold CTRL to select multiple items

* Do you speak any other languages besides English?:

Yes   No

If yes, please note other languages:

* How many years have you worked as a caregiver for older adults?:

Less than 1 year1 year to 2 years2 years to 3 years3 years to 4 years4 years or moreNone

* Please indicate the types of services which you are willing to provide (Click ALL that apply):

Companionship/Home HelperWalking assistanceBathing assistanceMedication remindersVacuum/sweep/mop/dust/laundry/iron/change linens/clean fridgeTotal incontinent care (changing adult briefs)Incontinence assistanceBedpan/bedside commode assistanceIndoor activities (games/cards)Outdoor activities (gardening, walking, fishing, etc.)Transportation to appointments, run errands, etc.Basic meal prep (soup, sandwich, boxed foods)Advanced meal prep (future meal prep/cooking from scratch)Work with female clientsWork with male clientsWork with a 2 client household * Hold CTRL to select multiple items

* I enjoy or have interests in (Click ALL that apply):

Television & MoviesCooking/BakingSportsArts & craftsScrapbookingGardeningChurch activitiesMusic Fine Arts & TheatreSewing Reading Current eventsHistoryOutdoor activities * Hold CTRL to select multiple items

* Are you willing to provide service to a client with a dog?:

Yes   No

* Are you willing to provide service to a client with a cat?:

Yes   No

* Are you willing to provide service to a client that smokes?:

Yes   No

Due to the nature of In-home Care for older adults, we cannot promise shifts nor guarantee the number of hours you will work.

* Total hours preferred to work per week:

* What type of job are you interested in:

Full-time   Part-time   Short-notice   Split Shift   Live-in

* When are you available:

Weekends   Overnights   Afternoons   Evenings   Mornings   Weekdays

Indicate days and hours you are available for work:

Day	From	To	And/Or	From	To
Monday			AndOr
Tuesday			AndOr
Wednesday			AndOr
Thursday			AndOr
Friday			AndOr
Saturday			AndOr
Sunday			AndOr

* Do you have reliable transportation?:

Yes   No

Is this vehicle insured with your name on the policy?:

Yes   No

Driver's License #:

Expiration Date:

State:

* How many miles from home are you willing to travel?:

* Are you willing to transport clients in your private vehicle?:

Yes   No

* Are you willing to drive a client's vehicle?:

Yes   No

Please provide your state and county of residence for the past 7 years, starting with the most recent residence.

State	County	From	To
*	*	*	*

* Have you been convicted of a felony within the last seven years?:

Yes   No

If yes, date of conviction:

* Have you had any moving violations in the past 7 years?:

Yes   No

If yes, describe:

* Have you been convicted within the last seven years of misappropriation of funds, embezzlement, or similar other dishonest conduct; or an offense involving the use of a weapon; for burglary, robbery, breaking and entering or theft; or physical assault or other violent crime?:

Yes   No

* Have you been convicted of or completed a period of incarceration within the past five years for any misdemeanor?:

Yes   No

If the answer to the above question is yes, please state whether you were convicted more than five years ago for any offense?:

Yes   No

* Have you ever been investigated for abuse, neglect or domestic violence?:

Yes   No

If yes, explain:

Please complete for all full-time or part-time employment, beginning with most recent employer. You may include as part of your employment history any verified work performed on a volunteer basis.

* Company Name:

* Address:

* Supervisor's Name:

* Telephone No:

* May we contact?:

Yes   No

* State job titles and describe job duties:

* Dates Employed (From/To):

* Reason for Leaving:

* Company Name:

* Address:

* Supervisor's Name:

* Telephone No:

* May we contact?:

Yes   No

* State job titles and describe job duties:

* Dates Employed (From/To):

* Reason for Leaving:

Company Name:

Address:

Supervisor's Name:

Telephone No:

May we contact?:

Yes   No

State job titles and describe job duties:

Dates Employed (From/To):

Reason for Leaving:

Please explain any gaps in your employment history:

Please list persons not related to you who know your qualifications.

* Reference Name:

* Telephone No.:

* Best time to call:

* Nature of Relationship (friend, co-worker, teacher, etc.):

* No. of Years Known:

* Reference Name:

* Telephone No.:

* Best time to call:

* Nature of Relationship (friend, co-worker, teacher, etc.):

* No. of Years Known:

* Reference Name:

* Telephone No.:

* Best time to call:

* Nature of Relationship (friend, co-worker, teacher, etc.):

* No. of Years Known:

* Reference Name:

* Telephone No.:

* Best time to call:

* Nature of Relationship (friend, co-worker, teacher, etc.):

* No. of Years Known:

Note: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Verification "Form I-9" be completed for every new hire and that within 3 business days of beginning work every new hire must present to the employer documentation establishing his/her identity and authorization to work. This federal requirement must be satisfied as a condition of employment.

I certify that, to the best of my knowledge, the answers given are true and complete and that purposeful misrepresentation may result in rejection of my application. I authorize investigation of all statements contained in this application, as required. Additionally, I authorize former employers, references and any other individual/organizations to provide information to A WAY TO STAY and I hereby release and discharge any of the above and A WAY TO STAY from any liability of any kind or nature. I also understand that it is my responsibility to keep such information current and accurate by updating it as often as necessary.

I hereby authorize National Crime Search, Inc to obtain a background check, consumer report, or investigative consumer report on me, as applicable.

I forever release, absolve, and indemnify to the fullest extent allowed by law National Crime Search, Inc., its affiliates, and all providers of information for releasing and obtaining any information arising from any and all sources.

I agree to a physical examination, if requested, and understand that failure to meet any medical and/or health requirements for the position may prevent my employment with the Agency. I also understand that employment, for certain positions, may be conditional upon successful completion of a substance abuse screening test, if part of the Agency's pre-employment policy.

I understand that, if hired, I may be required to provide proof that I am a citizen of the United States or proof that I am currently authorized to work in the United States.

I understand that, if hired, due to the nature of in-home care for older adults we cannot promise shifts nor guarantee the number of hours you will work.

I understand that this application is not a contract of employment. I also understand that if hired, regardless of any oral representations to the contrary, the employment relationship between Stay Home Strategies LLC d/b/a A WAY TO STAY and me is terminable at-will, so that both the company and I remain free to choose to end our work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing.

By means of an electronic signature I understand I am agreeing to the terms listed above.

* Signature (type name):

* Date: