Please Complete the Following Questionnaire
2+ Years of Experience Required
SKILLS
What Languages do you speak?
Education & Training
Check all that apply*
Credentials
Check all that apply*
Work Experience
Please provide past work experiences (references) for 3 Professional positions you have held in the Elder Care / Hospital/ Facility or Agency field ONLY (Please do not list any unrelated industry positions)
** helping your family members will not be considered as adequate experience
** Must be professionally paid work experience
** Remember, to be considered for an interview you must have a minimum of 3 Employment references, private care and IHSS are okay.
1.
Name of Employer
Name of Supervisor
Contact Number
Start Date
End Date
Start Wage / hr
End Wage / hr
Reason for Leaving
If NO, explain and offer an additional Work Reference
2.
Name of Employer
Contact Number
Start Wage / hr
End Wage / hr
Name of Supervisor
End Date
Start Date
Reason for Leaving
If NO, explain and offer an additional Work Reference
3.
Name of Employer
Contact Number
Name of Supervisor
Start Date
End Date
Reason for Leaving
Start Wage / hr
End Wage / hr
If NO, explain and offer an additional Work Reference
Do you currently have ads offering your domestic services to the General Public?
Personal References
Availability & Travel
Please let us know your Available Days
Equipment
Do you have the supplies and equipment to perform " Domestic Care" Services?
I certify that all answers given by me are true, accurate, and complete.
I authorize investigation of all statements contained in this application, providing a urine sample for a drug test and for a background check to be completed. I understad that misrepresentation or omission of facts in this application may be cause for invalidating my contract referral agreement with Beloved Comfort Home Care, a Referral Agency.
I hereby release any and all prior employers or current employers from liability or claims arising out of the provision of information about my employment with such employer. I hereby waive any cause of action I might otherwise have against such employer arising out of the provision of information concerning my employment.
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