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Caregiver Job Application

Applying for a position

There are two ways to apply for a caregiver position:

1. Fill out form below and submit online

2. Print job application and mail to:

         Handle With Care In-Home Care & Assistance
         P.O. Box 1008
         Elmhurst, IL 60126

         Caregiver Job Application Handle With Care - In-Home Care & Assistance in Chicago

Personal Information
First Name *
Middle Initial
Last Name *
Other/Previous Last Name
Social Security Number
Address *
Address (continued)
City *
State *
ZIP Code *
Home Phone *
Cell Phone
Email *
Drivers License Number *
Best way to contact you *
Birth Date *

Name, Address, Phone � next of kin *
How did you hear about Handle With Care? *
Would you like to refer a friend as a caregiver? (if so, name, phone)
I am available to work
Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Sundays
Time available *

Is your availability above flexible? *
Yes No
Are you available for a live-in position? *
Weekends    Yes No
Weekdays    Yes No
Are you able to fill in last minute, if a caregiver is not able to make it to work? *
Yes No
My ideal number of hours per week *
I can work in a home with a dog? *
Yes No
I can work in a home with a cat? *
Yes No
I can work in a home with clients who smoke? *
Yes No
Any other restrictions? *
I have a car, in good working condition *
Yes No
I have current auto insurance with
If hired, can you provide proof of citizenship or employment authorization? *
Yes No
I am able to work in * Du Page County
Cook County
Kane County
Will County
McHenry County
Kendall County

I speak English *
I am willing to prepare meals using predetermined recipes from Handle With Care *
Yes No
Licenses / Certifications
Type
State
License/Cert. Number
Expiration Date
Other Certifications
Basic Life Support
Advanced Cardiac Life Support
CPR
First Aide
Other
Personal References (Please do not list a relative)
Name *
Your relationship to reference *
Telephone number of reference *
Email address
Past Employment
Company / Facility *
Address *
Supervisor Name *
Supervisory Phone *
Type of Business *
Dates of Employment *
Salary / Pay Rate *
Reason for Leaving *
Describe job duties *

Company / Facility
Address
Supervisor Name
Supervisory Phone
Type of Business
Dates of Employment
Salary / Pay Rate
Reason for Leaving
Describe job duties

Company / Facility
Address
Supervisor Name
Supervisory Phone
Type of Business
Dates of Employment
Salary / Pay Rate
Reason for Leaving
Describe job duties

Education
Name, City, State Years Attended Degree/Certificate Did you graduate?
High School
Nursing/Tech School
College
Post-College
Other Training

Have you ever been convicted of a drug, assault or theft related misdemeanor? *
Yes No
If Yes, explain
Have you ever been in a medical-professional liability suit within the last 5 years? *
Yes No
If Yes, explain
Has your license / certification ever been suspended or revoked? *
Yes No
If yes, explain
Please Read Carefully
I certify that the information contained in this application is correct to the best of my knowledge and understand that falsification of this information is grounds for refusal to hire or, if hired, dismissal.

I authorize any insurance company, employer, educational institution, law enforcement organization, state or federal government agency, information service bureau, medical facility or practitioner, and any other person or organizations listed in this application to release information regarding my character, performance, qualifications, background, reasons for termination of past employment, and eligibility for rehire to Handle With Care, In-Home Care & Assistance LLC. I also understand that as a condition of my employment I will complete a background check including, but not limited to, criminal records, social security number verification, and driving record. I also authorize the release of my driving history and criminal records, and understand that it may contain information about my background, mode of living, character, and personal reputation. I understand that a criminal conviction is not an automatic bar from employment and will be reviewed for job related impact. I authorize you to request and receive such information, and release you and all parties involved in providing such information from any responsibility or liability. I understand that the decision to hire is solely that of Company.

As a condition of my employment with the Company, I agree that all information which I receive in the course of my employment relating in any manner to, among other things, the business activities, customers, production processes, financial affairs, programs, concepts or designs of Company are to be treated by me as trade secrets and kept in confidence, not to be disclosed to any unauthorized person either during or after my employment, or used by me in any manner adverse to the interests of Company. In addition, I may be required to sign a separate Invention and Confidentiality Agreement.

In consideration for my employment by Company, I agree to conform to the rules and regulations of the Company and acknowledge that these rules and regulations may be changed, interpreted, suspended, withdrawn, or added to by Company at any time, at the Company's sole option and without any prior notice to me.

I further acknowledge that my employment is at-will and may be terminated, and any offer of employment, if such is made, or my acceptance of an employment offer, if such is to occur, may be withdrawn, with or without cause, and with or without prior notice, at any time, at the option of the Company or myself. I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Company and myself for either employment or for providing of any benefit.

If my services terminate after accepting employment, I understand that Company, or any of its affiliates may supply, in confidence, my employment record to any prospective employer, with no liability to the Company or its staff.

I acknowledge that I have been advised that this application will remain active for no more than sixty (60) days from the date it was made. I agree to these terms:

Enter your full name as a signature of applicant *
Date of application *