Application for Employment - Silver Leaf In-Home Care

Date of Application

MM

DD

YYYY

Position Applied For:

Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Addresses for Past Three Years

In Case of Emergency, notify:

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Are you now employed?

Yes
No

If not, how long since leaving last employment?

How did you hear about Silver Leaf In-Home Care?

Education

Where did you attend school?

Highest Grade Completed?

Do you have any training for non-medical caregiving? If so, please explain:

Are you now or have you ever been certified or licensed to provide any form of health care?

License or Certificate held:

Who issued it and when?

Is it current?

Did it lapse or was it revoked?

When and why was it revoked?

Employment History

Please list your employment for the past three years, starting with your most recent position.

Position Held - Name and Address of Employer - Dates of Employment - Why did you leave?

For each of the following, please indicate which ones you have experience with:

Do you have lifting restrictions?

Please explain:

How much time lost from work due to illness during the last 3 years?

References

Please list at least three references. If you have previous caregiving experience, at least two references should be people you cared for or their relatives. If you worked for an agency, you would use them as a reference.

Reference 1 Name

First Last

Reference 1 Address

Street Address Address Line 2 City State ZIP Code

Reference 1 Phone Number

How long have you known this person?

Their relation to you:

Reference 2 Name

First Last

Reference 2 Address

Street Address Address Line 2 City State ZIP Code

Reference 2 Phone Number

How long have you known this person?

Their relation to you:

Reference 3 Name

First Last

Reference 3 Address

Street Address Address Line 2 City State ZIP Code

Reference 3 Phone Number

How long have you known this person?

Their relation to you:

Other

Have you ever been convicted of a crime?

Do you smoke?