Caregiver Employment Application Form   Personal Information PLEASE COMPLETE ALL QUESTIONS,PAGES 1-4 Date   Name Last : First : Middle : Present Address Street : City : State : Zipcode : D.O.B :             (mm/dd/yyyy) Age : Social Security No : Home Phone : Business Phone : Cell Phone : Please list age(if under 18) : Please Indicate the days and times you are available to work Anytime Mon - From : AM PM To : AM PM Tue - From :   AM PM To : AM PM Wed - From : AM PM To : AM PM Thu - From :   AM PM To : AM PM Fri - From :     AM PM To : AM PM Sat - From :    AM PM To : AM PM Sun - From :   AM PM To : AM PM Position Applied For : Have You Ever Applied here before? :  Yes   No Salary Range Desired : How many hours can you work weekly: Are you available to work nights? :  Yes   Some   None Are you available to work weekends? :  Yes   Some   None Would you consider live-in? :  Yes   No Employment Desired : PART - TIME ONLY FULL - TIME ONLY PART / FULL - TIME Are you legally authorized to work in the Us? :  Yes   No When you are available to start work? : Where did you hear about us? : E-Mail Address : Education Information TYPE OF SCHOOL NAME OF SCHOOL LOCATION(city,state) NUMBER OF YEARS COMPLETED MAJOR & DEGREE High School College Bus Or Trade School Professional School Have You ever been convicted of a crime?  Yes   No If Yes,explain number of conviction(s),nature of offense(s) leading to conviction(s),how recently such offense(s) was / were committed, sentence(s) imposed, and type(s) of rehabilitation (A conviction will not necessarily result in the denial of employement). Have You ever worked under a different name?  Yes   No If Yes,what was it and what was the reason? Do you have any relatives or friends thatn work for the company?  Yes   No If Yes,what is their name? In case of emergency please contact : Name : Relation : Home Phone : Business Phone :         || || || || || || || ||   License# 231346