An Extra Hand Home Care

Before starting this Application, please have the following available for upload: Drivers License, Social Security Card, CPR / First Aide / BLS Certification, CNA / PCA / Caregiver Certification, TB Skin / Chest X-Ray, CoVID19 Vaccination Card (Not Required), and Valid Car Insurance. You will not be able to submit application without documents attached.

Name *

First

Last

Birthday *//

Social Security Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

How did you hear about us

Type of employment desired *

Please Specify Days and Hours Available *

Position applied for *

Full-time
Part-time
PRN

Current hourly pay rate $

Desired pay per hour $ *

Are you legally eligible to work in the US? *

Yes
No

Are you available to work On Call, if needed? *

Yes
No

Have you ever been employed with us? *

Yes
No

If yes, when? //

Why did you leave?

Do you have any friends or family employed at this location? *

Yes
No

If yes, what is/are their name(s)?

Have you been convicted of a crime in the last seven (7) years? *

Yes
No

FYI: Conviction will not be a deciding factor in continuing the pre-screening process or potential employment opportunities

If yes, please explain

During the hiring process, do you agree to provide a criminal background check and drug screening? *

Yes
No

During the hiring process, do you agree to show proof of car insurance?? *

Yes
No

Educational Background: Please Answer The Following Questions - Institution 1 *

List previous educational history

Degree / Diploma

Field of study

Graduated *

Yes
No

Institution 2

Degree / Diploma

Field of study

Graduated

Yes
No

Institution 3

Degree / Diploma

Field of study

Graduated

Yes
No

Document Checklist - CNA / PCA / Caregiver Certification *

Yes
No

Name of Certification

Certification No

Expiration Date

CPR/ First Aid - Current *

Yes
No

Expiration Date

Driver’s License - Current *

Yes
No

Drivers License No *

License Number and Expiration Date

Expiration Date *

Are you CoVID19 Vaccinated (Not Required, but some clients require caregivers to be vaccinated) *

Yes
No

If Vaccinated, please upload CoVID19 Card with other documents below.

TB Screening - Current *

Yes
No

Expiration Date *

What do you think the most difficult part of caregiving or customer service work is? *

Ms. Jackson ask's you to apply BENGAY muscle rub on her back, what would you do? *

In what situations do we provide services not listed in the SERVICE PLAN? *

What is DNR? *

Why is it important to work within your scope or job description? *

EMPLOYMENT BACKGROUND - Employer Name 1: *

List your previous employers beginning with the most recent employer.

FROM *//

TO *//

Responsibilities: *

Adress *

Job Title: *

Supervisor Name/Phone: *

Reason for leaving: *

May we call to verify? *

Starting Hourly Rate *

Final Hourly Rate *

Employer Name 2:

FROM//

TO//

Responsibilities:

Adress

Job Title:

Supervisor Name/Phone:

Reason for leaving:

May we call to verify?

Starting Hourly Rate

Final Hourly Rate

Employer Name 3:

FROM//

TO//

Adress

Job Title:

Supervisor Name/Phone:

Reason for leaving:

May we call to verify?

Starting Hourly Rate

Final Hourly Rate

Personal Reference 1: *

List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please).

Relationship *

Years acquainted *

Phone Number *

Personal Reference 2: *

List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please).

Relationship *

Years acquainted *

Phone Number *

Personal Reference 3: *

List the name, relationship, number of years acquainted, and phone number of three references. (No relatives please).

Relationship *

Years acquainted *

Phone Number *

**CERTIFICATION AND RELEASE: (Print Your Name) *

I certify that I have read and understand the application note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief :.I understand that any false information, omissions or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumers reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I understand that I am not obligated to disclose sealed or expunged records of conviction or arrest. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, national origin, ancestry, veteran status, medical condition, sexual orientation, marital status or any other characteristic protected by applicable state or federal civil rights laws.

Applicant’s Signature *

Sign your name here

Today's Date *//

ID File Upload *

Upload a photocopy of your Driver license. If you're unable to upload document due to size, please email document to hr@anextrahandhomecarellc.com (Subject: Your Name / ID Verification Documents)

SS Card File Upload *

Upload a photocopy of your SS Card. If you're unable to upload document due to size, please email document to hr@anextrahandhomecarellc.com (Subject: Your Name / SS Card Verification Documents)

CPR / First Aide / BLS Certification File Upload

Upload a Copy of your CPR/ First Aid / BLS Certification. If you're unable to upload document due to size, please email document to hr@anextrahandhomecarellc.com (Subject: Your Name / CPR / First Aide / BLS Certification Verification Documents)

CNA / PCA / Caregiver Certification File Upload

Upload a Copy of your CNA/PCA/Caregiver Certification. If you're unable to upload document due to size, please email document to hr@anextrahandhomecarellc.com (Subject: Your Name / CNA / PCA / Caregiver Verification Documents)

TB Skin / Chest X-Ray File Upload

Upload a Copy of your TB Skin / Chest-Xray. If you're unable to upload document due to size, please email document to hr@anextrahandhomecarellc.com (Subject: Your Name / TB Skin / Chest X-Ray Verification Documents)

CoVID19 Vaccination Card File Upload (Not Required)

Upload a Copy of your CoVID19 Vaccination Card. If you're unable to upload document due to size, please email document to hr@anextrahandhomecarellc.com (Subject: Your Name / CoVID19 Vaccination Verification Documents)

Valid Car Insurance File Upload

Upload a Copy of your Valid Car Insurance. If you're unable to upload document due to size, please email document to hr@anextrahandhomecarellc.com (Subject: Your Name / Car Insurance Verification Documents)

Resume

Upload a Copy Resume. If you're unable to upload document due to size, please email document to hr@anextrahandhomecarellc.com (Subject: Your Name / Resume)

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