704 Mac Dade Blvd. Collingdale, Pa 19023 Phone: 215-631-3999 Email: hr@caresify.com APPLICATION FOR EMPLOYMENT Caresify is an equal opportunity employer and all applicants will be considered for employment without regard to race, religion, color, sex, national origin, age, marital or veteran status, medical condition or disability, or other status protected by law. Please let us know if you need accommodations in order to participate in the application process or assistance completing this form. NAME: Sex: M F PRINT Last First Middle ADDRESS: CITY: STATE: ZIP: PHONE: (Home) (Cell) Are you over 18 yrs of age? Y N Email Address: Preferred form of Communication: Email/SMS/Phone Native: (Please tick one) Black/Hispanic/White/Alaskan Native/Asian/Pacific Islander. Language: (1) Speaking/Writing (2) Speaking/Writing (3) Speaking/Writing Special Interest: Children, Sports, Computer Abilities, Pets, Reading, Singing, Dancing, Special Qualifications or Military Experience, Others Are you legally eligible for employment in the United States? Yes No (Verification is required by law.) I want to apply as (please choose one or all that applies from the following) Administrator/Program Director Personal Care Aide/Attendant Homemaker/Companion Care Coordinator Hourly rate desired: $ How did you hear about this position: Have you submitted an application here in the past? Yes / No If Yes, when? Have you ever been employed here before? Yes / No If yes when? CERTIFICATIONS: Certified Nursing Assistance (CNA) First Aid Training Medical Assistant CPR Training Home Health Aide (HHA) TB Screening (within past year) Licensed Practical Nurse (LPN) Registered Nurse Nursing Diploma OTHER CERTIFICATIONS: DRIVER S LICENSE #: DATE OF EXPIRATION / / DO YOU HAVE A CAR OR ACCESS TO ONE? YES / NO DO YOU HAVE PROOF OF AUTO INSURANCE? YES / NO POLICY # EXPIRY / / CAN YOU DRIVE CLIENTS TO DOCTOR S APPOINTMENTS AND/OR ERRANDS? AVAILABILITY (Please check all that apply): List Hours Available Please Circle: Live-In Only Hourly MONDAY AM PM. WEDNESDAY AM PM. TUESDAY AM PM THURSDAY AM PM. FRIDAY AM PM. SATURDAY AM PM. SUNDAY AM PM. Full Time_ Part Time_ Overnight only_ Weekends only_ 1
AREAS I CAN WORK: Bucks County Chester County Delaware County Montgomery County I CAN DO: (please check one or all that applies) Moderate Lifting & Transfers up to pounds Light Lifting & Stand-by assists up to pounds Heavy Lifting & Transfers up to pounds ALLERGIES Are you allergic to latex? Yes/No Are you allergic to animals? Yes/No, If yes, types? Do you smoke? Yes/No Allergic to smoke? Yes/ No Willing to work in a smoking environment? Yes/ No EXPERIENCE Abilities & Skills (Please select tasks for which you have experience. You will be tested! It is okay not to have experience in all or any of the following. Please select if you are willing to learn for areas you do not have experience) Bathing Assist: Yes/No/Willing to Learn Feeding Assist: Yes/No/Willing to Learn Dressing Assist: Yes/No/Willing to Learn Incontinence Care: Yes/No/Willing to Learn Stand-By Assist: Yes/No/Willing to Learn Meal Preparation: Yes/No/Willing to Learn Wheel Chair Assist: Yes/No/Willing to Learn Wash Laundry: Yes/No/Willing to Learn Companionship: Yes/No/Willing to Learn Hospice Care: Yes/No/Willing to Learn Alzheimer's Care: Yes/No/Willing to Learn Diabetes Care: Yes/No/Willing to Learn Terminal Care: Yes/No/Willing to Learn Mechanical Lift: Yes/No/Willing to Learn Medication Reminders: Yes/No/Willing to Learn CPR: Yes/No/Willing to Learn Personal Care Assistance: Yes/No/Willing to Learn First Aid: Yes/No/Willing to Learn Light Housekeeping (Dust, Vacuum & Laundry): Yes/No/Willing to Learn Lifting & Transfer Assistance: (helping a person from chair to standing position) Yes/No/Willing to Learn Ambulating Assistance: (ensuring a person's stability and safety when moving) Yes/No/Willing to Learn What kind of meals can you prepare? Please cite examples: Please list any other skill, which may be applicable to the position under consideration in the space below: Years of experience as a Caregiver? Are you certified by the state of Pennsylvania as a Caregiver? Are you able to perform the functions of the job for which you are applying with or without a reasonable accommodation? Yes / No Are you presently employed? Yes / No May we contact your previous employer? Yes / No / Later May we contact your present employer? Yes / No / Later Date you are available to start work? / / How far can you travel from home to work? 0-5 miles 6-10 miles 15 30 miles >30 Total hours of preference per week: CRIMINAL BACKGROUND Have you ever been convicted of a crime: Yes/ No. If yes, please explain Please list all names you have used in the past Last Name First Name Middle Last Name First Name Middle Last Name First Name Middle 2
Level of Education Name & Address Of School Major Subject Circle Last Year Completed Date Graduated & Degree/Diploma High School Diploma YES NO GED College 1 2 Vocational/ Technical University 1 2 3 4 Volunteer Experience: Employment History (please list most recent first; all employment gaps must be accounted for below): Former Employers will be contacted for Employment Verification and as References. If you do not want them contacted, please note that below, next to the contact person s name. Dates Employed: From: / to / Currently Working Yes / No Employer: Address: FT/PT/LIVE IN Verified by employer: Verification Date: / / Time: Results: Dates Employed: From: / to / Currently Working Yes / No Employer: Address: FT/PT/LIVE IN Dates Employed: From: / to / Currently Working Yes / No Employer: Address: FT/PT/LIVE IN 3
Dates Employed: From: / to / Currently Working Yes / No Employer: Address: FT/PT/LIVE IN EXPLAIN GAPS IN EMPLOYMENT HERE: 1) From: / to / Reason: 2) From: / to / Reason: Personal References: We will be contacting these references, please notify them in advance. (Do not include family members) We require 2 Positive References so please list as many as you can. 1. Name: Occupation: Relationship: Years/Months Known: Phone Number: 2. Name: Occupation: Relationship: Years/Months Known: Phone Number: 3. Name: Occupation: Relationship: Years/Months Known: Phone Number: THIS IS NOT AN EMPLOYMENT CONTRACT. Please ensure that all appropriate questions has been answered accurately and completely. False or misleading statements during the interview and on this form are grounds for terminating the application process and if discovered after employment begins, terminating employment. All qualified applicants will receive maximum consideration and will be treated with love and respect throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Child Clearance, Extensive Background Check, Physical examinations, TB test and additional testing for the presence of illegal drugs in your body is required prior to employment. We are non-discriminatory in employment and service. 4
704 Mac Dade Blvd. Collingdale, Pa 19023 Phone: 215-631-3999 Email: hr@caresify.com Applicant- Please just sign and date this form. Do not fill out any of the information. We use this for past employers if they can only give information with a signed release form. The person below has applied for employment with Caresify and has listed you as a previous employer. We would appreciate your assistance in verifying employment and evaluating job performance. ALL INFORMATION WILL BE KEPT CONFIDENTIAL ---AT YOUR EARLIEST CONVINIENCE, PLEASE COMPLETE AND FAX TO 215-631-3999 APPLICANT RELEASE Applicant: Last First Middle Maiden Company/Facility: Title: Social Security No.: Dates Employed: From To Pay Rate: For Employment Reference Release I authorize the individual or company completing this form to please release all information (including opinions) regarding my employment with them. I hereby release and hold harmless any person or company that provides this information, both factual and opinion, to Caresify, its representatives and agents from any legal liability for any damages that may result from the disclosure of this information. Applicant Signature EMPLOYER RESPONSE 1. Does the employment dates above correspond with your records? Yes No. If not, please provide the correct dates. Comments: 2. Is there anything in the individual s work history that would pose a threat to a patient safety? Yes No Comments: 3. Was this person ever disciplined for work-related conduct or incidents? Yes No If yes, please attach a sheet providing details. 4. Would you rehire this employee? Yes No POOR AVERAGE GOOD EXCELLENT Attendance Punctuality Dependability Quality of Work Job Knowledge/Skill Judgments Accepts Supervision Appearance Attitude/Cooperation Reason for leaving: Responsibilities and duties: Title: Company/Facility: Address: Phone #: Signature: Date 5
Please read carefully I hereby certify that the information contained in the above application form and in any attachments listed below (hereafter made as part of this application) is true, correct and complete to the best of my knowledge. I understand that any false statement I have made herein or my failure to disclose requested information may disqualify me for consideration for employment, or if employed, may result in my termination. I further authorize Caresify, or its agent to perform an investigation of local, state and federal records relating to any criminal convictions I may have. In addition, the agency has my permission to obtain all necessary information from the references I have listed or any other sources, concerning my prior employment, personal history, or criminal history and I release all parties from possible damages resulting from disclosing such information with or without prior written notice to me. I understand and acknowledge that I may be required to undergo a post-offer, pre-employment physical exam and a post-offer, pre-employment drug screening analysis for substance abuse. I understand that these may, to the extent permitted by law, result in the revocation of any offer of employment. I agree that Caresify may give any potential client my name and any information provided on this application and I release Caresify from any damages that may result from furnishing such information. I understand that no representative, other than the company president, has the authority to enter into any agreement for employment for any specified period of time. I certify that THIS APPLICATION DOES NOT CONSTITUTE AN EMPLOYMENT CONTRACT. I understand that the use of illegal drugs is prohibited during employment and I am willing to submit to drug testing to detect the use of illegal drugs during employment. I further acknowledge that, if I am offered a position and employed with Caresify, I agree that If during the course of employment, Caresify advances me money, or if I lose, destroy or fail to return any Caresify property, my signature is my authorization for Caresify to deduct from my wages sufficient funds to repay what I owe. I agree that I will represent the agency's best interest at all times, be the client's advocate and my employment and compensation may be terminated at any time, with or without notice or cause, except as otherwise provided by law. I have read and understood the above and I hereby endorse with my signature below. Applicant Name (please print) Applicant Signature Date We appreciate the time taken to complete this application. Please note that this application is valid for 60 days. Please check your emails for further advice and have your preferred means of communication open for our care coordinators to be able to reach you. If there is additional information you would like to include, please list it on a separate sheet of paper. FOR OFFICE USE ONLY PLEASE DO NOT WRITE ANYTHING BEYOND THIS POINT INTERVIEWED BY: DATE: TIME: NOTES: 6