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.
Name
Date
Street Address
City
State
ZIP
Phone
Email Address
Emergency Contact
Name
Phone
Address
Relationship
I am applying for a position as a
Have you ever been convicted of a felony?
yes no
If yes, please provide details
Transportation:
Many caregiver positions require the caregiver to transport a client.
Do you have dependable transportation?
yes no
Make and model of car
     
A Driver’s License and proof of auto insurance will be required at time of hire. Are you able to provide these?
yes no
Availability
Number of hours you would like to
work
Times you are available to work
Any times not available to work
Can you be called at the last
minute in case of emergency?
yes no
Comments
Education
High school
City/State
Did you Graduate?
yes no
Application for Employment
© 2010, The Senior’s Choice. All rights reserved. rev. 11/09 – page 1
For Papa’s Sake Home Care for Families
3403A N. Kennicott Ave
Arlington Heights, IL 60004
Job Line: (847) 870-0962
Phone: (847) 873-0234 Fax: (847) 873-0227
Application for Employment
College
City/State
Degree/ Major
     
Other
City/State
Field of Study
Degrees/certificates
Special skills or courses
Employment History
Please go back at least five years and tell us about your work history. Use reverse side of sheet if additional
space is required.
Application for Employment
© 2010, The Senior’s Choice. All rights reserved. rev. 11/09 – page 2
Foreign Language
In what foreign languages, if any, are you proficient to speak, read or write?
Experience
Discuss any training or experience working with the elderly
What would you like most about working with the elderly?
What would you like least about working with the elderly?
Companion-ship
yes no
Vacuuming
yes no
Laundry
yes no
Bathing/ dressing
yes no
Dusting
yes no
Grocery shopping
yes no
Grooming
yes no
Clean bathrooms
yes no
Cooking
yes no
Incontinence
yes no
Clean kitchen
yes no
Driving
yes no
Transfer assist
yes no
Bed linen
changes
yes no
Medication
reminders
yes no
May we contact your current employer?
yes no
Company
From
To
Job title
Reason left
Duties
Supervisor
Phone
Company
From
To
Job title
Reason left
Duties
Supervisor
Phone
Company
From
To
Job title
Reason left
Duties
Supervisor
Phone
Company
From
To
Job title
Reason left
Duties
Supervisor
Phone
Application for Employment
© 2010, The Senior’s Choice. All rights reserved. rev. 11/09 – page 3
Business References
Name
Address
Relationship/Years Known
Local Phone #
Name
Address
Relationship/Years Known
Local Phone #
Name
Address
Relationship/Years Known
Local Phone #
Name
Address
Relationship/Years Known
Local Phone #
Name
Address
Relationship/Years Known
Local Phone #
Personal References
Name
Address
Relationship/Years Known
Local Phone #
Name
Address
Relationship/Years Known
Local Phone #
Name
Address
Relationship/Years Known
Local Phone #
Name
Address
Relationship/Years Known
Local Phone #
Name
Address
Relationship/Years Known
Local Phone #
Application for Employment
© 2010, The Senior’s Choice. All rights reserved. rev. 11/09 – page 4
For our recruitment purposes
How did you learn of this position? Internet Newspaper Job Board Employment office Current employee Other
Please provide specific name of entity checked above:
CERTIFICATION AND RELEASE: 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.
Signature (type in name)
Date
For Office Use Only – Interviewer Comments
Application for Employment
© 2010, The Senior’s Choice. All rights reserved. rev. 11/09 – page 5
When complete, please email this
application to:
info@forpapassake.com
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