DuPage Will Family Caring Angels Application Form

* = Required Information

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

License State

Section 1 - General Information

Date Available? *

Job Type? *

Desired Position *

Drivers License Number *

Expiration Date *

Auto Insurance Expiration Date *

Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? *

Yes

Please explain

Provide your Social Security Number *

Days of week and times of day you are available *

Days of week and times of day you are NOT available *

Could we call you at the last minute in case of emergency to fill-in? *

Yes

Do you smoke? *

Yes

What are you allergic to? *

Do you have reliable transportation? *

Yes

Please provide, year, make and model of your primary vehicle *

Section 2 - Which of the following have you performed?

Companionship

Yes

Assisting someone with bathing

Yes

Assisting someone with dressing

Yes

Assisting someone with grooming

Yes

Changing adult disposable underwear

Yes

Transferring assistance

Yes

Assistance with wheelchairs

Yes

Assistance walking with gait belts

Yes

Assistance with Hoyer Lifts

Yes

Vacuuming floors

Yes

Dusting

Yes

Cleaning bathrooms

Yes

Cleaning kitchens

Yes

Doing laundry

Yes

Changing linens on an occupied bed

Yes

Grocery shopping

Yes

Cooking/Meal preparation

Yes

Driving others to appointments

Yes

Providing medication reminders

Yes

Section 3 - Employment Verification

Are you a U.S. citizen? *

Yes

Please indicate VISA type and number

Are you authorized to work in the U.S.? *

SectionSection 4 - Education

Name of High School *

Location of High School *

Did you graduate? *

Yes

Years Attended (From/To) *

Additional Education (vocational, undergraduate, etc.)

Yes

Please list the school name(s), dates attended and any certificates or diplomas

Section 5 - Other Training: Certifications/Licenses

Certifications/Licenses

Section 6 - Current Employment

Current Employer

Address

City

State

Zip Code

Start Date

End Date

Hours Worked

Position/Title

Describe Your Responsibilities

Supervisor's Name/Title

Supervisor's Phone

Reason for Leaving

May we contact?

Yes

Section 7 - Employment History

Last Employer

Address

City

State

Zip Code

Start Date

End Date

Hours Worked

Position/Title

Describe Your Responsibilities

Supervisor's Name/Title

Supervisor's Phone

Reason for Leaving

May we contact?

Yes

Section 8 - Business References

Reference 1: Name *

Relationship *

Years known *

Phone *

Reference 2: Name

Relationship

Years known

Phone

Reference 3: Name

Relationship

Years known

Phone

Section 9 - Personal Reference

Reference 1: Name *

Relationship *

Years known *

Phone

Reference 2: Name

Relationship

Years known

Phone

Reference 3: Name

Relationship

Years known

Phone

Section 10 - Emergency Contact Information

First Name *

Last Name *

Address

City

State

Zip Code

Phone 1 *

Phone 2

Relationship *

Section 11 - Other Information

Any other information we should know about you?

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.