Caregiver Application Form

Personal Information
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Educational Background  New Educational Background

Employment History  New Employment History

Please provide your latest employer information below.

Skills/ Preferences

Availability
Cooking Skills

Experience












General
Language

Level of Ability
Personal Care

Pets
Transportation


Vehicle Type

References   New Reference

Miscellaneous Questions

Q.) Please tell us about your professional background as a LVN, Caregiver, CNA, Home Health Aide, or IHSS professional.
Q.) How did you hear about ASSURED CARE?
Q.) Why did you decide to leave your previous Jobs?
Q.) How would your past employer(s) describe your work ethics?
Q.) What skills do you possess, that make you a good Care Professional?
Q.) Are you at least 18 years of age?
Q.) What hours are you available to work for ASSURED CARE?
Q.) Are you a US citizen, and able to work legally in the United States?
Q.) What other languages do you speak? If Applicable.
Q.) Have you ever been convicted of a crime over the age of 18? If so, was it expunged, pardoned, annulled, dismissed, or sealed contingent upon completing your probation? If yes, please state the conviction(s) below and this does not dismiss the possibility for employment if there is a record. Assured Care is an Equal Opportunity Employer, and this will assist us in evaluating your application.
Q.) Have you ever had or licensed suspended or convicted of any moving violations?
Q.) Have you ever been discharged, suspended, or asked to resign from a position, or have you resigned to avoid from being fired? If yes, please explain below.
Q.) Final Submission and Disclaimer: Congratulations. You have now completed the application process for employment with ASSURED CARE. Once you have submitted this application, you agree that all your information is true, and to the best of your knowledge accurate. Any information that is falsified or found to be untrue, automatically dismisses your application. By submitting this application, you authorize Assured Care to release information regarding reference checks. Also, if selected for an in-office interview, and offered pre-screened employment upon completion of the interview, you MUST consent to a drug test, criminal background check, and to have your driving record checked. Furthermore, contingent upon employment with Assured Care all care professionals will have to successfully complete their registration as a Home Care Aide with the Home Care Service Bureau (Department of Social Services). Please sign your name below to acknowledge your approval for submission of this application.

* Caregiver Signature

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