Careers Form

* = Required Information

Personal Information

Your Full Name:*

Date:

Date of Birth: *

Gender*

Social Security No:

Street Address:*

City:*

State

Zip Code:

Phone*

Cell:

Email*

How did you hear about us?

Do you smoke?

General Information

Are you 18 years or older?*

Are you a U.S. citizen or have a legal right to be employed in the U.S?

(If yes proof is required)

Do you own or have access to a car for work?

Have you ever been convicted of a felony or a misdemenour?

If Yes, please explain

**Conviction of a felony or misdemenour will not automatically disqualify you from employment.

Availability:

How soon are you available to work?

Education

High School:

Years attended

Graduated

GED:

Years attended

Graduated

College:

Years attended

Graduated

Years attended

Graduated

Other:

Years attended

Graduated

Employment History

List below five years of recent, verifiable work history starting with most recent employer.

Employer:

Phone #

Job Title

Earnings

From:

To:

Address:

City:

State

Zip:

Duties and Responsibilities:

If still employed, may we contact your present supervisor?

If yes, please give phone #:

Supervisor:

Title:

Reason (s) for Leaving

Employer:

Phone #

Job Title

Earnings

From:

To:

Address:

City:

State

Zip:

Duties and Responsibilities:

If still employed, may we contact your present supervisor?

If yes, please give phone #:

Supervisor:

Title:

Reason (s) for Leaving

Employer:

Phone #

Job Title

Earnings

From:

To:

Address:

City:

State

Zip:

Duties and Responsibilities:

If still employed, may we contact your present supervisor?

If yes, please give phone #:

Supervisor:

Title:

Reason (s) for Leaving

Skills:

Please indicate whether or not you have assisted with or performed the following tasks for seniors.

Companionship

Yes

Transportation

Yes

Trach care

Yes

Bathing/Dressing

Yes

Meal prep/Clean up

Yes

Colostomy Care

Yes

Grooming

Yes

Light Housekeeping

Yes

Ventilator

Yes

Transfer assists

Yes

Hospice Care

Yes

Stroke

Yes

Laundry

Yes

Okay with Smokers

Yes

Dementia

Yes

Hoyer Lift

Yes

Okay with dogs/Cats

Yes

Parkinsons

Yes

Ambulation

Yes

Feeding

Yes

Alzheimer's

Yes

Incontinence care

Yes

Medication Reminders

Yes

Diabetes Monitoring

Yes

References:

Give the names of three persons not related to you

Name:

Relationship:

Years known:

Phone #:

Name:

Relationship:

Years known:

Phone #:

Name:

Relationship:

Years known:

Phone #:

APLICATION WAIVER FORM

(Please read carefully before signing)

I understand and acknowledge that, unless otherwise defined by applicable law or written agreement with Blissful Home Care, any employment relationships with the Company is considered "employment at will", which means the employee may resign at any time and the Employer may discharge the Employee at any time, with or without cause. I have read, understand and agree to the above statement.
If I should be employed by the Company, I understand that any false, incomplete, or misleading information given on this application or during an interview shall result in immediate discharge. I have read, understand and agree to the above statement.
I authorize an inquiry into my background by all persons, schools, companies, corporations, credit bureaus, law enforcement agencies, doctors and other consumer reporting agencies to supply information concerning my previous employment, education, credit, driving record, etc. I have read, understand and agree to the above statement.
I authorize the references listed above to give representatives of Blissful Home Care, any and all information concerning my previous or current employment and any pertinent information they may have, personal or otherwise, and release all parties from any and all liability from any damage that may result. I have read, understand and agree to the above statement.

Signature of Applicant

Date:

RN	LPN	CNA	CPR
First Aide

Monday	Tuesday	Wednesday	Thursday
Friday	Saturday	Sunday