Employment Application Form

Your Name*
,

Gender:*

Present Address*
Contact Number*
Second Contact
E-mail Address*

Checked regularly* YesNo

Please list all allergies
Driver's License #* State*
Valid?* YesNo
Expiration Date*
Type*

Accidents over the past 3 years?* YesNo if so how many?
Moving violations over the past 3 years?* YesNo if so how many?
How do you get to work?* DriveBusCabOther

How did you hear about us?* AdFrom EmployeeSomeone else


Position applying for*
Date Available*
Are you interested in:* Full time 30-40 hours/weekPart time 20- 30 hours/weekDay shiftsEvening shiftsOvernight shifts

Education
High School Diploma / GED* YesNo
College Degree* YesNo

Other Licenses and Certifications
Are you a CNA or HHA?* YesNo
Do you have a current CPR certification?* YesNo
If you answered Yes to any/both of these questions, please let us make a copy of the appropriate paperwork


Special Skills/Experience Caring for Elders

Experience caring for elders?* YesNo

Are you able to lift at least 45 pounds?* YesNo
Are you able to climb stairs, bend and stand for long periods of time?* YesNo

 

Military

Have you ever served in the Armed Forces? YesNo
If so, specialty
Date Entered Discharged

Are you currently in the National Guard? YesNo
If so, specialty
Date Entered Discharged


Prior Applications

Have you applied at Elder Care Connections before?* YesNo
If so, when?

 

Work History (Previous 3 years)*
Please list your last three contactable places of work

Previous Employer 1
Supervisor:
Date started Date left

Job Title: Pay:
Valid Company phone number:
May we contact this employer? YesNo

Reason for leaving

Previous Employer 2
Supervisor:
Date started Date left

Job Title: Pay:
Valid Company phone number:
May we contact this employer? YesNo

Reason for leaving

Previous Employer 3
Supervisor:
Date started Date left

Job Title: Pay:
Valid Company phone number:
May we contact this employer? YesNo

Reason for leaving


Professional References*
It is essential for you to fill out current telephone numbers for all your references.


Name

Address

Valid Tel #
 

Name

Address

Valid Tel #
 

Name

Address

Valid Tel #

Did you complete this application yourself?* YesNo
If not, who did?

Did you live anywhere outside Indiana during the two years directly before today?* YesNo

Because majority of our clients require care on weekends you will be required to work at least every other weekend. Are you available to work?* YesNo

We Serve in Monroe and other surrounding counties. You may be asked to serve in these surrounding counties. Can you work in these counties?* YesNo

Why have you chosen to work with the elderly?*

 

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Elder Care Connections, Inc.

Professional Senior Home Care
  • Located in the South Court Professional Building
  • 239 E. Winslow Rd.
    Bloomington, IN  47401
  • Phone: (812) 330-3771
  • Fax (812) 287-8468
  • Email us
  • Staffed with experienced care providers who are available 24 hours a day, 365 days a year.

Map & Directions

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