Lifeline Home Care Application Form

Application Form

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, medical condition, national origin, or marital status.

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - Personal Information

Name (First and Last) (required)

Address (required)

Date of Birth (required)

Phone Number (required)

(Numeric Answer Only)

Email Address (required)

Emergency Contact #1 (First and Last) (required)

Emergency Contact #2 (First and Last) (required)

Section 2 - Employment & References

What position are you applying for? (required)

Have you ever submitted an application with us before?

Yes No

What is your current employment status? (required)

Have you ever been employed with us before? (required)

Yes No

How did you hear about our Lifeline Home Care franchise?

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Have you been given a copy of the job description for the position for which you have applied to review?

Yes No

Why are you interested in employment with us?

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Are you willing to provide service to a client that smokes?

Yes No

Are you willing to provide service to a client with a pet?

Yes No

If yes, which one:

Valid Driver's License and State License was Issued (required)

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Means of Transportation

Section 3 - Availability

Available start date (required)

Please complete all areas of availability: (required)

Please indicate the days of the week as well as the earliest and latest times that you are available for work (required)

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Section 4 - Education/Credentials

Grade School (Please select highest grade completed.)

High School (Please select highest grade completed.)

College (Please select highest grade completed.)

Please list schools attended. (Include school name, city and state, major or subject, years attended, and if you graduated)

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Do you have any license/certificate? (required)

Yes No

List all certifications and licenses you have.

Certification of Health Date (required)

CPR Training Date (required)

Tuberculin Skin Test Date (required)

Section 5 - Employment History (Most Recent Employer)

Current Employer (required)

Are you currently working for this employer? (required)

Yes No

If yes, may we contact?

Yes No

Company Address (include street address, city, state, and zip) (required)

Phone Number (required)

(Numeric Answer Only)

Date Employed To

Date Employed From

Duties

Reason for Leaving (required)

Section 6 - Employment History (Second Most Recent Employer)

Company Name

Address (include street address, city, state, and zip)

Phone Number

(Numeric Answer Only)

Date Employed From

Date Employed To

Duties

Reason for Leaving

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Section 7 - Employment History (Third Most Recent Employer)

Company Name

Address (include street address, city, state, and zip)

Phone Number

(Numeric Answer Only)

Date Employed From

Date Employed To

Duties

Reason for Leaving

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Section 8 - Skills & Language

Describe any training or life skills you have that apply to caring for a senior:

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Describe any work history you have that would apply to caring for a senior:

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What do you like (or think you would like) most about working with older adults?

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What do you like (or think you would like) least about working with older adults?

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What personal rewards do you get from working with seniors?

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Section 9 - Personal Reference 1

Name (First and Last) (required)

Phone (required)

Email Address (required)

Number of years known (required)

Section 10 - Personal Reference 2

Name (First and Last)

Phone

Email Address

Section 11 - Background Check & Certification

Are you at least 19 years of age? (required)

Yes No

List states and counties of residence for the past seven years: (required)

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Have you had any moving traffic violations? (required)

Yes No

If yes, please describe:

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Have you been charged/convicted of a felony and/or misdemeanor/or served time (required)

Yes No

If yes, please describe:

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I certify that all information is correct and accurate.

Yes No

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

Signature