Eldercare Application  
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ONLINE ELDER CARE APPLICATION
 
Preferred Employment type (Check One)

Live In Caregiver
Hourly Caregiver
 
Personal Information
Social Security Number  
E-Mail:  
First Name:  
Last Name:  
Address Line 1:  
City:  
County  
State:  
Zip Code:  
Home Phone:  
Mobile Phone:  
DOB:  
Marital Status:  
Gender  
Weight  
Height  
Emergency Contact Name  
Emergency Contact Number  
Is English your first or second language  
What is your Nationality?  
Other languages you speak fluently  
States willing to relocate:   ex: MD,VA,MA,CT
Do you Drive?  
Will you drive your Car to work?  
License Number:  
State:  
 
Work Preference
Companion Care: shopping, errands   Explain your experience
Personal Care: bathing, dressing   Explain your experience
Housekeeping: vacuuming, dusting   Explain your experience
Cook/Prepare Meals   Explain foods you can cook
Help with Pet Care  
Date Available:  
Position Apply For:  
State:  
Weekly Live-In Salary:  $
Hourly Live-Out Salary  $
Employment Requested:
Live-In/7 days
Live-In/Weekdays
Live-In/Weekend
Full Time/Live-Out
Part Time/Live-Out
Available to work on Holidays
Yes     No
Available for
Emergengy/Short Notice
Yes     No
 
Experiences: Very Important - check only those
you have 3 months or more hands on experience!
Blood Pressure Check  
Glucose Blood Sugar Check  
Colostomy Bag  
First Aid Certified  
CPR Certified  
Alzheimer`s/Dementia  
Cancer  
Diabetes  
Hospice  
Other Experiences
/Interest/Hobbies 		 
 
Education
High School Name/Location:  
Diploma Received:
Diploma
Equivalency
None
College Name/Location:  
Degree Earned:  
Attended from:   MM/DD/YYYY
Attended To:   MM/DD/YYYY
Major/Minor:  
 
Vocational/Nursing School  
Location/Address  
Attended From   MM/DD/YYYY
Attended To   MM/DD/YYYY
Certificate/Diploma  
 
Employment History
Name Of Employer:  
Address Line 1:  
Address Line 2:  
City:  
State:  
Zip Code:  
Employed From:   MM/DD/YYYY
Employed To:   MM/DD/YYYY
Employer Phone:  
Job Title:  
Supervisor Name:  
Reason For Leaving:  
 
Name Of Employer:  
Address Line 1:  
Address Line 2:  
City:  
State:  
Zip Code:  
Employed From:   MM/DD/YYYY
Employed To:   MM/DD/YYYY
Employer Phone:  
Job Title:  
Supervisor Name:  
Reason For Leaving:  
 
Professional References
Please list two references that have
knowledge of your professional experience.
Reference Name:  
Address:  
Position:  
Phone:  
 
Reference Name:  
Address:  
Position:  
Phone:  
 
Personal References
Reference Name  
Address  
Occupation  
Phone:  
 
Reference Name  
Address  
Occupation  
Phone:  
How did you hear about us?  
 
Background
HAVE YOU EVER BEEN CONVICTED
OF A FELONY OR A FIRST DEGREE MISDEMEANOR?
Yes
No
AVE YOU EVER PLED NO CONTEST OR GUILTY TO
A FELONY OR A FIRST DEGREE MISDEMEANOR?
Yes
No
ARE YOU A U.S. CITIZEN OR ARE YOU LEGALLY
AUTHORIZED TO WORK IN THE U.S.?
Yes
No


The above information is true and correct. If employed, I will be required to provide original documents which verify my identity and right to work in the United States under the Immigration Reform and Control Act (IRCA) of 1986. I hereby do authorize Attentive Care, Inc. to obtain all confidential employment, background check & references needed for employment.
Acknowledgement & Signature  
Date Signed   Ex: MM/DD/YYYY

 

 

 

  
 
 
 
 
 
 
 
 
 
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