Summarize special caregiver skills and qualifications acquired from previous employment or experience.

Summarize the formalized training that you have received?

How long have you worked as a caregiver? Give an example of one of your best caregiving experiences and an example of one of your most challenging caregiving experiences.

What is your Home Care Aide Registry number?

What is the date of your last TB test?

How did you hear about us?

When can you start?

What days and hours are you available for work?

What are your long-term dreams and aspirations? Please include both personal and professional goals. :

Please list any languages, other than English, that you speak fluently: :

Please list two Emergency Contacts and their contact phone numbers. 1) Name: Phone: Relationship: 2) Name: Phone: Relationship:

If employed by Caring Companions At Home and in consideration thereof, I understand and agree to: 1. I certify that the answers given by me to the forgoing questions and statements on the employment application and or during the employment interview process are true and correct without any consequential omissions of any kind whatsoever. I understand that any misleading or incorrect statements may render this application void and, if employed, would be case for my termination. I further agree that Caring Companions At Home shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me in this application. 2. I authorize the companies, schools, persons or entities given during the employment process, internal investigations, or on this employment application as references or past employers or affiliations to give any information regarding my employment, character, qualifications, certifications and licenses and hereby release said companies, schools, persons or entities from all liability for any damage for issuing this information. 3. I understand that I may be required to have a medical examination and/or drug and alcohol test after an offer of employment has been made and prior to the commencement of my employment duties. A favorable result on the medical examination and/or drug and alcohol test would be a condition of my employment or commencement of any employment duties. 4. I understand that my employment is not for a specified or definite term and that I may resign, or I may be discharged, at any time with or without prior notice. I further understand that this policy cannot be changed or amended except by written agreement signed by me and by a corporate officer. 5. My employment shall be in accordance with the terms of this application, all safety and incident reporting rules, and all other Caring Companions At Home rules, regulations, policies and procedures currently or hereafter in effect. 6. I understand that as an employee of Caring Companions At Home I will be on probation for the first 90 days. 7. I certify that as a part of the application process, I have been provided with a written job description or have had the opportunity to review and/or discuss the requirements for the available position. I understand each requirement and certify that I am capable of meeting each and every requirement. I also understand if the position for which I am applying requires licenses and/or certifications; it is my responsibility and a requirement for continued employment to maintain valid licenses and/or certifications.