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Angel Caregivers Inc. Application Form

Please complete application as completely and accurately as possible.

PERSONAL INFORMATION

Are you over the age of 18?

Are you over the age of 18?

Are you a US Citizen?

Are you a US Citizen?

Have you lived in Illinois for 2 years or more?

Have you lived in Illinois for 2 years or more?

EMPLOYMENT INFORMATION

Position Desired

Part Time or Full Time?

Part Time or Full Time?

Shift Preference

Shift Preference

Days Preference

Days Preference

Salary Desired

Date available to start work

Do you posses a valid driver's license?

Do you posses a valid driver's license?

Do you have your own transportation?

Do you have your own transportation?

Have you applied here before?

Have you applied here before?

How were you referred to us?

How were you referred to us?

QUALIFICATIONS AND EXPERIENCE

Education:

High School

College/Technical Training

Language Spoken in addition to English

Can you perform all of the job-related position(s) for which you are applying?

Can you perform all of the job-related position(s) for which you are applying?

Do you have a current CPR certification?

Do you have a current CPR certification?

Why do you want to work for this agency?

PAST & PRESENT EMPLOYERS

Current Employer

Supervisor:

May we contact your supervisor for reference?

May we contact your supervisor for reference?

Do you have a previous employer?

Do you have a previous employer?

REFERENCES

(Give work or medical field related references. Do not list, relatives or personal friends)

Reference # 1

Phone Number

Address

How do you know this person?

How many years acquainted?

Add 2nd reference

Add 2nd reference

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?

Have you ever been found guilty of, or pleaded no contest to, any criminal offense more serious than a minor traffic violation?

EMERGENCY CONTACT

Emergency Contact Name:

Relationship to you:

Address (Emergency):

Phone Number (Emergency):

"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 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."
Signature