A Better Choice Home Care - For all your personal care needs.

A Better Choice Home Care (Job Application)
Today's date:
First and Last Name
Maiden Name or other Aliases
Complete Physical Address and Mailing address Please include your Zip Code or PO box
County
Phone Number (cell)
Cell Carrier (Required For state mandated EVV system)
Current Email Address (required)
Birth Date
Social Security Number (Must complete with app)
Do you currently own a vehical?
State Vehical License # (don't leave blank)
What is your Race, Ethnicity and Language Spoken
Eye Color
Hair Color
Emergency Contact information including Name and Phone #
What certifications do you have?
PSS
CNA
DSP/DSL
CPR
Highest grade completed High School
Reference 1 (Include Company name Phone# Address and supervisor name)
Dates of Employment with this job?
Reason you left this job?
Reference 2 (include Company name, Phone# Address and Supervisor name)
Dates of employment with this job?
Reason you left this job?
Reference 3 (Include Company or personal name, Phone # Address and Supervisor name)
Dates of employment with this job?
Reason you left this job?
Availability
Days
Over Nights
Mornings
Afternoons
Evenings
Weekends
Part Time
Full Time
On Call

Days you are avaiable to work
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What hours a day can you work? Be specific as possible
How many hours a week can you work?
Are you willing to work with both male and femail clients? Please elaborate
Skills you are trained for
Bathing, Hygiene
Shampoos
Skincare
Shaving
Dressing
Meal Prep
Housekeeping
Laundry
Transportation
Errands
Incontinence care
Medication reminders
Feeding
Catheter care
Any Work related restrictions or limitations
Speech
Hearing
Lifting
Health
Physical
Emotional
Transportation
Are you a Felon?
Do you have misdemeanors? explain
Have you been ivestigated for any of these reasons
Domestic Abuse
Elder Abuse
Misappropriation
Drug use
Neglect
Other
Are you currently involved in any court proceedings? Or any state investigations?
Are you legally authorized to work in this country
Tell me about yourself?
Home care requires you to have a PSS certificate. Being a CNA allows you to work for us as a CNA( but your duties are only as PSS) for only the time that it takes to get your test out done for the PSS certification. Are you willing to take the final exam to get a PSS certificate if you don't currently have one?
How did you hear about our agency?
I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that the withholding, misrepresentation or falsification of information shall be grounds to refuse employment, or, if employed, shall be grounds for dismissal.Sign Here
Thank you for submitting your application!