Caregiver Application

We are always looking for caregivers. To be considered for a position please fill out the form below. After reviewing your application we will get back to you.

Name*
First Middle Last
Status*
Internal Notes*
Email*
Enter Email Confirm Email
Phone
Cell Phone
Position(s) applied for*
Refferal Source*
- Advertisement
- Employee
- Relative
- Walk-in
- Internet
- State Employment Agency
- Private Employment Agency
- Other
Other
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How long at this address?*
What days and hours are you NOT available for work?
Have you previously worked at Customized Care?
Are you legally eligible to work in the United States? (Proof of eligibility required.)
Applicants considered for hire will be subject to a thorough background screening process that includes a criminal background check and may include a motor vehicle check and drug screen. (Please note that some positions require you to be insured and bonded.)
Do you have reliable transportation to and from work and for travel between worksites, if required?
- Yes
- No
Do you have relative currently employed at Customized Care?*
- Yes
- No
If yes, please list:
Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodations?
- Yes
- No
If no, then list the functions that cannot be performed:
High School/GED Background
High School/GED Name, City*
Hoe many years attended?*
Graduated?*
- Yes
- No
Did you attend college?*
- Yes
- No
College Background
College Name/City*
How many years attended?*
Graduated?*
- Yes
- No
Course/Major*
Employement History
List your last three (3) employers, assignments, or volunteer activities, starting with the most recent, including military experience.
Employer 1 Name*
Employer 1: Telephone*
Employer 1: Date Employment Started (month and year)*
Date Format: MM slash DD slash YYYY
Employer 1: Date Employment Ended (month and year)*
Date Format: MM slash DD slash YYYY
Employer 1: Summarize the nature of the work performed and job responsibilities*
Employer 1 Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer 1: Job Title*
Employer 1: Immediate Supervisor and Title*
Employer 1: Starting Hourly Rate/Salary*
Employer 1: Reason for leaving*
Employer 1: Final Hourly Rate/Salary*
May we contact your refrences?
- Yes
- No
- Later
Employer 2 Name
Employer 2 Telephone
Employer 2: Date Employment Started (month and year)
Date Format: MM slash DD slash YYYY
Employer 2: Date Employment Ended (month and year)
Date Format: MM slash DD slash YYYY
Employer 2: Summarize the nature of the work performed and job responsibilities
Employer 2: Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer 2: Job Title
Employer 2: Immediate Supervisor and Title
Employer 2: Starting Hourly Rate/Salary
Employer 2: Reason for leaving
Employer 2: Final Hourly Rate/Salary
Employer 2: May we contact for reference/verificaton?
- Yes
- No
- Later
Employer 3 Name
Employer 3 Telephone
Employer 3: Date Employment Started (month and year)
Date Format: MM slash DD slash YYYY
Employer 3: Date Employment Ended (month and year)
Date Format: MM slash DD slash YYYY
Employer 3: Summarize the nature of the work performed and job responsibilities
Employer 3 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer 3: Job Title
Employer 3: Immediate Supervisor and Title
Employer 3: Starting Hourly Rate/Salary
Employer 3: Reason for leaving
Employer 3: Final Hourly Rate/Salary
Employer 3: May we contact for reference/verificaton?
- Yes
- No
- Later
Employer 3: Comments and other skills, licenses/certifications and qualifications:
References
List name and telephone number of three professional references that are NOT related to you. If not applicable, list three school or personal references that are not related to you, whom have knowledge of your work ethic, experience, and abilities.
Reference #1 Name*
Reference #1 Telephone*
Reference #1 Years Known*
Reference #1 Relationship*
Reference #2 Name*
Reference #2 Telephone*
Reference #2 Years Known*
Reference #2 Relationship*
Reference #3 Name*
Reference #3 Telephone*
Reference #3 Years Known*
By submitting this form I certify that the facts contained in this application and/or interview(s) are true and complete. Any misrepresentation or falsification of information or significant omissions will be cause for rejection of my application or for subsequent discipline up to and including my dismissal from employment if discovered at a later date.
I understand that, if employed, my employment is not guaranteed for any term, and my employment may be terminated by the employer or myself at any time and for any reason with or without notice. No representative of Customized Care other than the owner(s) is authorized to make any assurance or promise of continued employment and any such assurance must be in writing signed by the owner(s).
The employer, Customized Care, is an Equal Opportunity Employer. The employer does not discriminate in employment and no questions on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state, or federal law.

High School/GED Background

College Background

Employement History

References