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Angel Caregivers Inc. Application Form
Please complete application as completely and accurately as possible.
PERSONAL INFORMATION
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*
*
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Are you over the age of 18?
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Are you over the age of 18?
Yes
No
Are you a US Citizen?
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Are you a US Citizen?
Yes
No
Have you lived in Illinois for 2 years or more?
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Have you lived in Illinois for 2 years or more?
Yes
No
EMPLOYMENT INFORMATION
Position Desired
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Part Time or Full Time?
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Part Time or Full Time?
Part Time
Full Time
Shift Preference
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Shift Preference
Days Preference
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Days Preference
Salary Desired
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Date available to start work
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Do you posses a valid driver's license?
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Do you posses a valid driver's license?
Yes
No
Do you have your own transportation?
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Do you have your own transportation?
Yes
No
Have you applied here before?
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Have you applied here before?
Yes
No
How were you referred to us?
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How were you referred to us?
Facebook
How were you referred to us?
I saw your flyer somewhere
How were you referred to us?
Twitter
LinkedIN
Online search (Google search)
Indeed
Instagram
How were you referred to us?
Online job post
Craiglist
Company Website
Current employee of Angel Caregivers
Other:
QUALIFICATIONS AND EXPERIENCE
Education:
High School
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College/Technical Training
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Language Spoken in addition to English
Can you perform all of the job-related position(s) for which you are applying?
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Can you perform all of the job-related position(s) for which you are applying?
Yes
No
Do you have a current CPR certification?
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Do you have a current CPR certification?
Yes
No
Why do you want to work for this agency?
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PAST & PRESENT EMPLOYERS
Current Employer
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*
*
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Supervisor:
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May we contact your supervisor for reference?
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May we contact your supervisor for reference?
Yes
No
Do you have a previous employer?
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Do you have a previous employer?
Yes
No
REFERENCES
(Give work or medical field related references. Do not list, relatives or personal friends)
Reference # 1
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Phone Number
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Address
How do you know this person?
How many years acquainted?
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Add 2nd reference
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Add 2nd reference
Yes
No
CRIMINAL BACKGROUND INQUIRY
Have you ever been found guilty of, or pleaded no contest to, any criminal offense more serious than a minor traffic violation?
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Have you ever been found guilty of, or pleaded no contest to, any criminal offense more serious than a minor traffic violation?
Yes
No
EMERGENCY CONTACT
Emergency Contact Name:
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Relationship to you:
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Address (Emergency):
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Phone Number (Emergency):
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"I certify that all information provided in this application is true and complete to the best of my knowledge. I understand that if I am employed, any false statements discovered on this application will be grounds for immediate dismissal. I authorize the investigation of all statements contained in this application and give permission to all references listed above to provide any relevant information, whether personal or otherwise. I release all parties from any liability that may result from furnishing this information."
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"I certify that all information provided in this application is true and complete to the best of my knowledge. I understand that if I am employed, any false statements discovered on this application will be grounds for immediate dismissal. I authorize the investigation of all statements contained in this application and give permission to all references listed above to provide any relevant information, whether personal or otherwise. I release all parties from any liability that may result from furnishing this information."
I Agree
Signature
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Submit
