Apply for In- Home Caregiver

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:	In- Home Caregiver
ID:	1676
Location :	Rexburg, ID
Salary Range:	$13-$16
Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:

Employment Application

Date of Birth:

Employment History #1

* Are you currently employed?

	Yes
	No

Company Name

Job Title

From

Phone Number

May we contact?

	Yes
	No

Reason for leaving

Employment History #2

Company Name

Job Title

From

Phone Number

May we contact?

	Yes
	No

Reason for leaving

Education

School

* Did you graduate?

	Yes
	No

* Degree Received?

	Yes
	No

Emergency Contact

* Name

* Relationship

* Phone Number

Skills and Certifications

Please check the tasks below that you have experience with and or are willing to complete.

List any additional certifications you hold (e.g CNA, CPR, Medication Certified).

Preferences

* Are you available for all hours? (M-F 8:00am to 5:00pm)

	Yes
	No

If NO, please list availability

* Desired hourly wage

DISCLAIMER, AUTHORIZATION, AND SIGNATURE

I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions, or misrepresentation of facts will result in rejection from this application and; or discharge at any time during employment period. I authorize Caregivers NW to verify any and all information contained within this application, but not limited to, criminal history and motor vehicle driving records. I authorize Caregivers NW (CGNW) to contact me using the contact information (telephone, email, and address) provided on this employment application. Method of contact may include but is not limited to phone call, video call, conference call, voicemail, text message, email, and; or physical mail.

* Signature

* Date

Homecare Questionnaire

* Are you at least 18 years or older? (If no, you may be required to provide authorization to work)

	Yes
	No

* Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment)

	Yes
	No

* Have you ever worked for this Company before?

	Yes
	No

* Do you have a valid driver's license?

	Yes
	No

* Do you have a clean Driving Record; clear of major traffic violations and/ or auto accidents?

	Yes
	No

* Do you have a reliable vehicle with Auto Insurance to assist clients with needs outside of the home?

	Yes
	No

* Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodation?

	Yes
	No

If no, please explain

* Are you available to work between Monday - Friday?

	Yes
	No

* Are you available to work between the hours of 8:00 am-5:00 pm if needed.

	Yes
	No

I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.

Submit

Cancel

	Incontinence
	Cooking and meal prep
	Bathing/Dressing
	Companionship
	Transporting clients
	Hoyer lift
	Gait belt
	Client transfers
	Alzheimer's/Dementia

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	Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
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	White (Not Hispanic or Latino) A person having origins in any of the original peoples of Europe, North Africa, or the Middle East
	Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands
	Two or More Races (Not Hispanic or Latino) All persons who identify with more than one of the above races
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	Individual with a Disability An individual with a disability is a person who has a physical or mental impairment which substantially limits one or more of such person's major life activities, or who has a record of such impairment.
	Vietnam Era Veteran A person who 1) Served on active duty for a period of more than 180 days, and was discharged or released therefrom with other than a dishonorable discharge, if any part of such active duty occurred; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases; or 2) Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed; a. in the Republic of Vietnam between February 28, 1961, and May 7, 1975; or b. between August 5, 1964, and May 7, 1975, in all other cases.
	Disabled Veteran 1) A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) A person who was discharged or released from active duty because of a service-connected disability.
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	Armed Forces Service Medal Veteran A veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order No. 12985. To identify the military operations that meet this criterion, check your DD Form 214, Certificate of Release or Discharge from Active Duty.
	Recently Separated Veteran Any veteran during the three-year period beginning on date of such veteran's discharge or release from active duty in the U. S. military, ground, naval or air service.
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