Seniors Helping Seniors Application Form
Application Form
We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.
Personal Information
First Name
*
Last Name
*
Home Phone
*
Work Phone
Mobile Phone
Email
*
Address 1
*
Address 2
City
*
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*
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--
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Section 1 -
Personal Information
First Name
(required)
Middle Name
Last Name
(required)
Address
(required)
City
(required)
zip code
(required)
(Numeric Answer Only)
Phone Number
(required)
Email address
(required)
Section 2 -
General Information
Date Available?
(required)
Effective Date
*
Job Type?
(required)
-- Select an Option --
Full Time
Part Time? Set Schedule
On Call
Any
Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other?
(required)
Yes
No
Section 3 -
Employment Verification
Are you a U.S. citizen?
(required)
Yes
No
If you are not a U.S. citizen, please indicate VISA type and number.
Are you authorized to work in the U.S.?
(required)
-- Select an Option --
I am authorized to work in the U.S. for any employer.
I am authorized to work in the U.S. only for my current employer.
I require sponsorship to work in the U.S.
I do not know my work status.
Section 4 -
Other Training: Certifications/Licenses
Certifications/Licenses:
Show Plain Text
Section 5 -
Current Employment
Current Employer:
Start Date:
End Date:
Position/Title:
Reason for Leaving:
Show Plain Text
May we contact?
Yes
No
Section 6 -
Employment History
Last Employer:
(required)
Start Date:
End Date:
Position/Title:
(required)
Reason for Leaving:
(required)
Show Plain Text
May we contact?
(required)
Yes
No
Section 7 -
Restrictions on the job
Concerns working in a smoking environment?
(required)
Yes
No
Any physical restrictions or limitations
(required)
Yes
No
Concerns working around pets?
(required)
Yes
No
Section 8 -
What service(s) would you want to provide?
Meal Preparation
(required)
Yes
No
Light Housekeeping
(required)
Yes
No
Personal Grooming/dressing
(required)
Yes
No
Toileting/Bathing assistance
(required)
Yes
No
Companionship/Socialization
(required)
Yes
No
Dementia/Alzheimer's care
(required)
Yes
No
Overnight supervision (10-12 hours)
(required)
Yes
No
Transportation
(required)
Yes
No
Medication Reminders
(required)
Yes
No
Pet care/Pet walking
(required)
Yes
No
Section 9 -
Days/Times available to work
Monday
(required)
Tuesday
(required)
Wednesday
(required)
Thursday
(required)
Friday
(required)
Saturday
(required)
Sunday
(required)
I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.
Signature
Submit Application
