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     Home Phone No.

     Cellular Telephone No.

     What is the position you are applying for?

     Are you able to perform the essential functions of the position you are applying for? Yes   No   

     Are you lawfully authorized to work in the U.S.? Yes No

     Do you have reliable transportation to get to a work assignment on time? Yes No

     Are you capable of reading, writing, and understanding English as part of performing job related duties?           Yes No

     Do you speak any languages other than English? Yes No  If yes, please list:     

     Do you have access to a telephone and will you respond to job assignments in a timely manner?

         Yes No

     Do you have hands-on experience providing care services?  Yes No

     Please give us the name and telephone number of a contact person in the event we cannot get a hold of you:

     Name:    Number:

     On what date are you available to start work?

     What types of cases are you willing to work?:

          Hourly                  Yes No

          Shifts AM            Yes No

          Shifts PM            Yes No

          24 Hr Shifts        Yes No

     What days of the week and times of the day are you available to work?

     Days and Hours Available   

                           Sat                         Sun                                Mon                          Tue          

     Anytime       Yes                 Yes                         Yes                    Yes  

     From:                                                                           

                 AM  PM     AM  PM          AM  PM        AM  PM       

     To:                                                                                     

                 AM  PM     AM  PM          AM  PM         AM  PM

                           Wed                                  Thu                                   Fri

      Anytime      Yes                               Yes                                   Yes

      From:          AM  PM       AM  PM       AM  PM      

      To:              AM  PM       AM  PM       AM  PM      

     What days of the week and times of the day are you not available to work?

Professional and Technical Information

     Are you licensed or certified in any capacity of health or home care? Yes No If Yes, the name of  License or Certification:          

           Expiration Date:

     Issuing State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusettes Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming     License/Certification Number

     Has your license/certification ever been revoked or suspended?  Yes No

     If yes, state reason(s) for, date(s) of revocation or suspension, and date(s) of reinstatement.

     Are you CPR certified?   Yes No    

     Have you had a current TB Test?   Yes No  

     Do you have the test results available?   Yes No

     Have you obtained a high school diploma or GED certificate?   Yes No

    School Name & Location Diploma/Degree Subject Of Specialization

     College/University

     Specialized Courses and Training

     OTHER SPECIAL SKILLS - List Other Specific Skills You Have to Offer for This Job Opening: