Etched Quality Care

Applicant Information:

First Name*:

Middle Name*:

Last Name*:

Address*:

State*:

Postal Code*:

Phone:

Email*:

Hours wanted weekly:

Education & Training:

School/College:

Degree received:

Certifications and Credentials:

Please check all that apply, and enter the expiration date and any notes as applicable.

Active	Type	Expiration Date
	Car Insurance
	Chest X-Ray
	CNA License
	CPR Certification
	Driver's License
	First Aid Certification
	HHA Certification
	LVN/LPN Certification
	Passport
	Performance Evaluation
	Registered Nurse
	State ID Card
	Tuberculosis Test

Employment History:

Please provide your most recent positions of employment.

Employer:

Phone Number:

Address :

City:

State:

Date Employed:

To:

Employer:

Phone Number:

Address :

City:

State:

Date Employed:

To:

Employer:

Phone Number:

Address :

City:

State:

Date Employed:

To:

Professional References:

Please provide professional references.

Name:

Phone Number:

Name:

Phone Number:

Name:

Phone Number:

Additional Information:

Are you legally authorized to work in the United States? (Yes or No) Employment is subject to verification of US citizenship or authorized alien status in accordance with Immigration Reform and Control Act of 1986 after a conditional offer of employment is made.

List Emergency Contacts - Names/ Relationship to you/ Phone numbers:

Have you ever been convicted of a felony? (Yes or No):

IMPORTANT: All caregiver positions at Home Care Assistance are considered Temporary (seasonal) due to the frail condition of our elderly clients. Continued employment is not guaranteed for any caregiver as all employment is at-will, indefinite and not for any specific period of time. Please indicate your agreement by typing your initials below:

What days are you available for work (Monday - Sunday)? Specify each day along with AM/PM next to day. (Example: M-F 6 am - 12 pm and Saturday and Sunday 6 am - 12 pm). Are you available for days, nights, live in and/or weekends?

This job may require you to transfer up to 75 pounds of dead weight to bed, commode, wheelchair, couch, etc. Are you able to perform this task? (Yes or No):

How far are you willing to drive from home to work with a client?

If hired, when are you available to start work?

Please list the job skills that you have experience and will perform: (Patient Positioning, Colostomy Care, Bed Bath, Oxygen Administration, Catheter Care, Skin Care, Bed Pan, Assistance in Ambulating, Patient Transferring, Hoyer Lift Transfer, Feeding Tube, Assistance in Bathing, Range of Motion Experience, Assistance in Dressing, Assistance in Toileting):

Signature:

I agree that the above mentioned details are true.

Name:

Sign On:

EMPLOYMENT APPLICATION FORM

ETCHED QUALITY CARE

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General

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