Application Form

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Section 1 - General Information

Job type applying for? (required)

Available Start Date? (required)

Availability: please fill out below

Please list your availability for Monday (required)

Please list your availability for Tuesday (required)

Please list your availability for Wednesday (required)

Please list your availability for Thursday (required)

Please list your availability for Friday (required)

Please list your availability for Saturday (required)

Please list your availability for Sunday (required)

Can you provide documentation of a valid driver's license and auto insurance? (required)

Yes No

Do you have reliable transportation? (required)

Yes No

If yes: car make, model, year, and color (required)

Do you understand that drug testing may be required? (required)

Yes No

Are you available to work some nights and weekends because we are a 24/7 agency? (required)

Yes No

If no, please explain.

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How many miles are you willing to drive for work? (required)

Section 2 - Employment Verification

Hourly rate expectations? (required)

Are you authorized to work in the U.S.? (required)

Have you ever worked in homecare before? (required)

Yes No

If yes, what type of duties have you performed?

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Are you fluent in English written and spoken communication skills? (required)

Yes No

Have you ever taken care of a family member? (required)

Yes No

If yes, length of time you provided care?

Describe what type of care you provided and what duties you performed (e.g. showering, personal care, incontinence care)?

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Name and phone number of family member to verify caregiving experience

Section 3 - Education and Certifications

Please select an education or certification option below: (required)

If you are a certified CNA, MA, or HHA: Is your certification current?

Yes No

Certification State (if certified)

High School Graduate or GED?

Yes No

College

Yes No

College - years completed or degree received?

Other certifications, skills, or training?

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Section 4 - Skills and Preferences

Have you received the appropriate training to perform transfers of care recipients? (required)

Yes No

Are you able to transfer from bed to wheelchair, using your own body weight? (required)

Yes No

Are you able to transfer care recipients using a Hoyer Lift? (required)

Yes No

Do you have any physical limitations that may prevent transferring of a care recipient? If so, please explain (or put none if no limitations): (required)

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Competency Task List: Level 1 - please select Yes or No

Yes No

Medication Reminders (required)

Yes No

Light Housekeeping (required)

Yes No

Laundry (required)

Yes No

Errands/Shopping (required)

Yes No

Meal Preparation/Reminders (required)

Yes No

Competency Task List: Level 2 - Do you have any experience with the following?

Incontinence Care? (required)

Yes No

Bathing Assistance? (required)

Yes No

Grooming/Hygiene Assistance? (required)

Yes No

Competency Task List: Level 3 - Do you have any experience with the following?

Bedbound care? (required)

Yes No

Memory care (Alzheimer's/Dementia)? (required)

Yes No

End of life care? (required)

Yes No

Are you willing to work with the following?

Males? (required)

Yes No

Females (required)

Yes No

Dogs? (required)

Yes No

Cats? (required)

Yes No

Smoking? (required)

Yes No

Are you willing to drive care recipients? (required)

Yes No

Section 5 - Hiring Criteria

I understand that to be considered for a position with Visiting Angels all hiring criteria must be met. (required)

Yes No

Section 6 - Employee References (Professional)

Employer Name (required)

Address (required)

Phone Number (required)

Contact (required)

Start Date

End Date

Reason for Leaving

Job Title (required)

Wage (required)

May this person be contacted for a reference? (required)

Yes No

Employer Name (required)

Address (required)

Phone Number (required)

Contact (required)

Start Date

End Date

Reason for Leaving

Job Title (required)

Wage (required)

May this person be contacted for a reference? (required)

Yes No

Employer Name (required)

Address (required)

Phone Number (required)

Contact (required)

Start Date

End Date

Reason for Leaving

Job Title (required)

Wage

May this person be contacted for a reference? (required)

Yes No

Section 7 - Applicant's Statement

I hereby certify that I have not knowingly held back any information that might badly affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant have personally completed this application. I understand that any leaving out or misstatement of important facts on this application or on any document used to get employment shall be grounds for rejection of this application or for immediate firing if I am employed, regardless of the time passed before discovery. (required)

Yes No

I hereby authorize Visiting Angels to thoroughly investigate my background and as a result I will be requested to complete an Authorization to Obtain Consumer and Investigative Consumer Report form. I understand that any offer of employment is contingent upon receipt of a satisfactory report concerning my background check, MVR, academic credentials and employment references. I further understand that any false information, misleading statements or omission of facts will be sufficient cause for rejection of my application if the Agency has not employed me and for immediate dismissal if the Agency has employed me. (required)

Yes No

I understand that nothing contained in the application, or conveyed during any interview that may be granted or during my employment, if hired is intended to creat an employment contract between the Company and myself. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and my be terminated at any time, with or without prior notice, at the option of either the Company or myself, and that is no promises or representations contrary to the foregoing are binding on the Company unless made in writing and signed by me and the Company's designate representative. (required)

Yes No

I hereby acknowledge that I have have read and understand the preceding statements. (required)

Yes No

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.

Signature

Visiting Angels Application Form

Personal Information

Section 1 - General Information

Section 2 - Employment Verification

Section 3 - Education and Certifications

Section 4 - Skills and Preferences

Section 5 - Hiring Criteria

Section 6 - Employee References (Professional)

Section 7 - Applicant's Statement