Employment form

Thank you for your interest in working for our agency.

Please submit the application below to be considered for a position as a caregiver/ Direct Support Professional.

Applicant Information:

First Name*:
Middle Name*:
No Middle Name*:
Last Name*:
Address*:
Address Line 2*:
City*:
State*:
Postal Code*:
Home Phone*:
Mobile Phone*:
Email*:
Hours Wanted Weekly*:
Date of Birth*:

Please select checkboxes that match your skills and preferences.

General

Domentia Experience:
Hospice Experience:
Incontinence Experience:
Insured Automobile:
Live-In Shifts OK:
OK with Client Smoking:
Gait Belt Experience:
Hoyer Lift Experience:
ok with Cats:
ok with Dogs:
Max Client weight for transfers*:

**education and training*:**

High School Collage
School*:
Degree Recieved*:
Certifications and Credentials
Please Check all that apply, and enter the expiration date any notes as applicable

Active	Type	Expiration Date
	Car Insurance
	CNA License
	CPR Certification
	Driver License
	First Aid Certification
	HHA Certification

Employment History

Please Provide your most recent positions of employment

Employer
Supervisor
Phone Number
Address 1
Address 2
City
State
Postal Code
Date Employed To

Professional Refrences

Please Provide Professional Refrences

Name
Phone Number

Additional Information

Are you at least 18 years of age? Please answer yes or no

How did you hear about Mothers Assist Elderly

If hired, can you provide proof of your legal eligibility to work in the United States? Please answer yes or no. If no , please explain

Mothers Assist Elderly is an Equal Opportunity Employer, does not discriminate in hiring or terms and conditions of employment because of an individual’s race, religion, color, sex, national origin, marital status, sexual orientation, disability, genetic information, veteran status or other legally protected basis. Please answer all questions as completely possible. We encourage applications from qualified individual with disabilities. Please explain if you need any accommodations to participate in the application process. :

Do you have at least six months or more of Home Care experence? Yes or No

Do you have your own vehicle that is: reliable, insured and is with you during your shift? Yes or No

What days and hours are you available to work?

Can you stoop, bend and lift up to 50 pounds? Yes or No

Do you have experience doing live-in work? Yes or No. if so, are you available to do live in work? Yes or No

Do you have hospice experience? Yes or No

Do you have experience using a hoyer lift? Yes or No

Are you willing to work with clients who have pets in their home? Yes or No

Please provide two Emergency Contacts. Name, relationship and phone numbers

PLEASE READ CAREFULLY: I certify the information contained in this application is correct to the best of my knowledge. I understand owner may refuse to hire me if I falsify, misrepresent or omit information, or if I am hired, to terminate me. I authorize any of the persons or organizations referred to in this application to give you all information, personal or otherwise, with regard to any of the subjects covered by this application. I will conform to owner’s policies and procedures and acknowledge they may be changed, interpreted, suspended, withdrawn, or added to by owner at any time, at owner’s sole option and without any prior notice to me. I understand my employment is at-will and may be terminated, and any offer of employment, or my acceptance of an employment offer, may be withdrawn, with or without cause, and with or without prior notice, at any time, at the option of owner or me. I understand no representative of owner other than the President, and then only in writing, signed by both of us, has any authority to enter into any employment agreement for any specified period of time, or to assure any other personnel action, either prior to the start of my employment or after I have become employed, or to assure any benefits, or terms and conditions of employment, or make any agreement contrary to the foregoing. I understand nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between owner and me for either employment or for providing any benefit. I acknowledge any offer of employment to me by owner is contingent upon my timely completion of USCIS Form I-9, owner applications materials, and such other documents as may be required, and my producing the proper documents required by the Immigration Reform and Control Act of 1986. My failure to meet these requirements within the specified time will result in withdrawal of the offer or the termination of my employment. I understand my employment and continued employment, if hired, is contingent upon the results of periodic credit reports, and expressly authorize owner to obtain such credit reports in accordance with the Fair Credit Reporting Act. If I am terminated, I understand owner or any of its affiliates may supply, my employment record to any prospective employer and release owner of any liability or damages to me for doing so. By submitting this application I hereby agree, acknowledge, and understand the above referenced information is true and correct and that the submission of the same is the legal equivalent of my manual signature which binds me to the terms and conditions in this Agreement. If you have any additional information that you think would be helpful please add it here (optional). :

I accept all the terms and conditions