A Better Choice Home Care - Job Application - Windsor, ME
A Better Choice Home Care - For all your personal care needs.

Employment Application
First Name
Middle
Last/ Maiden/ Other Alias
Address: Street
Apartment # P O Box
City
State
Zip
Home Phone
Cell Phone
Email Address
Date of Birth
SSN
Gender
Male
Female
Emergency Contact & Phone Number
Education
Diploma
PSS Certificate
CNA
First Aid
CPR Certified
Work Limitations
Hearing
Speech
Lifting
Health
Physical
Emtional
Other
Availability for work
Full Time
Part Time
Short Notice
Split Shift
Days you are available to work
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Time you are available
7AM - 7PM
7PM - 7AM
Mornings
Afternoons
Evenings
Work Experience
Bathing/Showering
Grooming
Personal Hygeine
Dressing
Bowel Care
Bladder care
Feeding
Ambulation
Toileting
Housekeeping
Laundry
Meal Prep
Shopping/ helping to create a list
Transportation
Medication remindering
Health Maint tasks( Vent, O2, ect
Do you hold a valid Maine drivers license
Are you willing to
Transport consumers
Drive the consumer's vehicle
Escort a consumer in their own vehcle
Escort a consumer in public transportation
Do you have adequate vehicle insurance
Have you ever been investigated for alligations of
Sexual Abuse
Elder Abuse Neglect
Misapropriation
Drugs or OUI
Do you have any Misdemeanors
Are you a Felon
Reference 1 Company Name:
Address:
Phone
Supervisor's Name and email address
Dates of employment
Reason for leaving
Reference 2 Company Name
Address
Phone
Supervisor's Name and email address
Dates of employment
Reason for leaving
Reference 3 Company Name
Address
Phone
Supervisors Name and email address
Dates of employment
Reason for leaving
Any incomplete information will make this application void.I do certify that the answers given are true and complete and purposeful misrepresentation will result in rejection. I authorize investigation of all statements.

Thank you for you interest in
A Better Choice Home Care