Your Name: *

Your Email: *

Your Phone: *

Your Address (Incl. City / State / Country / Zip / Postal Code): *

Have you ever worked under a different name? * Have you ever worked under a different name? * Yes No

Do you speak English proficiently? * Do you speak English proficiently? * Yes No

Are you currently licensed as: * Are you currently licensed as: * HCA HHA Cert. RN CNA LVN/LPN Cert. First Aid Cert. CPR Cert. Other None

Do you have/active: * (check all that apply) Do you have/active: * (check all that apply) TB Clearance Chest X-Ray Passport State ID Card Live Scan Background Check NM Driver's License Car Registration & Insurance

Are you willing to use your car? Are you willing to use your car? Yes No I don't drive/don't own a car

Why did you choose this career? *

Previous Experience (2 Years Minimum) * Please include names, email addresses and phone numbers of AT LEAST 3 previous agencies or clients we may contact. You can also email us your resume to supplement this information. (To be considered for an interview you must have a minimum of 3 employment references in the Elder Care field.)

Experience Level (general) Experience Level (general) ALL NONE Companionship Cooking/Meal Preparation Light Housekeeping Out of Home Activities Car Transportation Dr. Appt./Errands/Shopping Light Exercise Monitor/Wandering Med Reminders

Experience Level (assistance) Experience Level (assistance) ALL NONE Feed Bath/Shower/Sponge Dress/Groom Ambulation Cane/Walker/WheelChair/Scooter Toileting Gait Fall Risk

Experience Level (advanced care) Experience Level (advanced care) ALL NONE Feeding Tubes Transfers Hoyer Briefs For incontinence/accidents Colostomy Dementia Wound Care Bedbound Hospice Care

Are there any caregiving tasks you aren't able or willing to perform?

Total Client Weight That You Can Support With Or Without Reasonable Accommodation (numbers only)

How do you get along with smokers, cats, dogs, or any other pets?

What day(s) are you available * (Note: It is not necessary to indicate the need for absences due to religious practices or obligations.) What day(s) are you available * (Note: It is not necessary to indicate the need for absences due to religious practices or obligations.) All Days Mon Tues Wed Thurs Fri Sat Sun

What shift(s) do you prefer? * (Please check all that apply) What shift(s) do you prefer? * (Please check all that apply) Day Evening Overnight Live In

What's your desired hourly wage?

How far are you willing to travel?

If you currently have ads placed offering your services for domestic care, please let us know where: If you currently have ads placed offering your services for domestic care, please let us know where: Care.com Caregiverslist.com CareLinx.com Craigslist.org MyCNAJobs.com Other

Anything else you'd like us to know?