Employment Inquiry Employment Inquiry Name* First Last Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code How were you referred to us?*Walk-InEmployeeNewspaper AOFacebookTwitterCraigslistGoogleOtherHave you ever worked as a caregiver in a senior agency before?* Yes No How long have you worked as a caregiver?*NeverLess than 1 year1-3 yearsMore than 3 yearsDo you have any active certifications? (i.e. CNA, PCA, HHA)* Yes No If you answered "yes" to the question above - which one(s)?What categories do you have experience in? (select all that apply)* Companionship Housekeeping Preparing and Serving Meals Alzheimer's/Dementia Personal Care (bathing, dressing, toileting) Transferring Other Upload Resume Drop files here or Accepted file types: jpg, pdf, docx, doc, rtf. What shifts are you interested in?* Hourly Live In Overnight Mornings Only Afternoons Only Willing to work any shift What days are you available?* Monday Tuesday Wednesday Thursday Friday Saturday Sunday Do you have a valid drivers license?* Yes No Do you own your own car?* Yes No If hired, can you present evidence of your right to work in the United States?* Yes No Do you have the ability to pass a comprehensive criminal background, reference, and drug screen?* Yes No Any other comments?