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Angel Caregivers Inc. Application Form
Please complete application as completely and accurately as possible.
PERSONAL INFORMATION
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Are you over the age of 18?
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Yes
No
Are you a US Citizen?
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Yes
No
Have you lived in Illinois for 2 years or more?
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Yes
No
EMPLOYMENT INFORMATION
Position Desired
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Part Time or Full Time?
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Part Time
Full Time
Shift Preference
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Days Preference
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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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Yes
No
Do you have your own transportation?
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Yes
No
Have you applied here before?
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Yes
No
How were you referred to us?
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Facebook
I saw your flyer somewhere
Twitter
LinkedIN
Online search (Google search)
Indeed
Instagram
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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Yes
No
Do you have a current CPR certification?
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Yes
No
Why do you want to work for this agency?
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PAST & PRESENT EMPLOYERS
Current Employer
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Supervisor:
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May we contact your supervisor for reference?
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Yes
No
Do you have a previous employer?
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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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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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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 Agree
Signature
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Submit
