EMPLOYMENT APPLICATION
for Davis In-Home Care, Inc.

This application may NOT work from a cell phone. If you try to fill it out and do not get a confirmation page, we will not receive it. In that case, we suggest using a tablet or computer, available at most libraries.

Company policy and federal and state law prohibit discrimination due to sex, race, color, gender, religion, national origin/ancestry, citizenship, age, physical or mental disability, medical condition, marital status, sexual orientation, gender identification/orientation, disabled veteran status, Vietnam-era veteran status, or any other characteristic protected by federal or state law.

* REQUIRED INFORMATION

POSITION APPLYING FOR:

DATE:

 
NAME (Last) (First) (Middle) Have you ever used another name? If so, list:
PRESENT ADDRESS (Number and Street) (City) (State) (Zip Code)
Have you lived in any other counties or states in the past 7 years? If so, please list with dates:
HOME PHONE #: CELL PHONE #: Best contact number:  

May we also contact you via email?  If yes, please provide your email address:


Are you at least 18 years of age?
 

If under 18, can you submit a work permit?  

Do you have the legal right to work in the United States?       

This position requires driving. Do you have your own car, a valid California drivers’ license and insurance?      

Have you ever been convicted of a crime other than (1) a marijuana-related conviction that occurred more than two years ago; (2) an offense for which you were referred to, and participated in, any pre-trial or post-trial diversion program; and (3) any conviction for which the record has been judicially expunged, sealed or eradicated such as juvenile records; and any misdemeanor conviction for which probation has been completed and the case has been judicially dismissed?    

If Yes, state the nature of the crime, when and where convicted, and disposition of the case:

NOTE: This Company will not deny employment to any applicant solely because the person has been convicted of a criminal offense. This Company, however, may consider the nature, date and circumstances of the offense, as well as whether the offense is relevant to the duties of the position applied for.

Are you currently under arrest on bond or on your own recognizance, pending trial for a criminal offense?  

The State of California 2016 Home Care Services Consumer Protection Act (HCSCPA) requires that all non-medical caregivers working for a registered HCO (Home Care Organization) supply the following 3 documents. Do you have:

Live Scan Fingerprinting   Current TB Test   HCA Registration  

How did you learn of this position?


- Give name of item(s) checked or explain if other:

Education

  School Name City and State # of Years Attended Did You Graduate? Degree/Major
High School

Junior College

College or University

Other

Other training, certificates or special skills?

Experience

Discuss any training or experience working with the elderly.
What would you like most about working with the elderly?
How many years of experience do you have working with the elderly?

Skills

Please indicate whether you have assisted with or performed the following tasks for seniors.
Companionship

  Vacuuming

  Laundry

Bathing

  Dusting

  Grocery Shopping

Grooming or Dressing

  Clean Bathrooms

  Cooking

Incontinence

  Clean Kitchen

  Driving

Transfer Assist

  Bed Linen Changes

  Medication Reminders

Please review the tasks above. Are you able to perform the essential functions of this job, either with or without reasonable accommodation?

If no, describe the functions you cannot perform:

NOTE: We comply with the ADA and FEHA and consider reasonable accommodation measures that may be necessary for eligible/qualified applicants/employees to perform essential functions.  Hire may be subject to passing a medical examination, and skill and agility tests, based on the job requirements.

Additional Information

Days & times you are available to work
Number of hours you would like to work each week?
Times you are not available to work
Date you can start
Desired Pay

A driver's license and proof of insurance will be required at time of hire. Do you have your own dependable car?

Foreign languages: proficiency to speak, read or write?

Employment History

Starting with your most recent employer, list at least 4 work references we can call, even if they are not related to caregiving.
Employer name, city and state
Employed from date:
Employed to date:
Job title Reason for leaving
Duties:
Pay Supervisor Phone

May we contact this employer?


Employer name, city and state
Employed from date:
Employed to date:
Job title Reason for leaving
Duties:
Pay Supervisor Phone

May we contact this employer?


Employer name, city and state
Employed from date:
Employed to date:
Job title Reason for leaving
Duties:
Pay Supervisor Phone

May we contact this employer?


Employer name, city and state
Employed from date:
Employed to date:
Job title Reason for leaving
Duties:
Pay Supervisor Phone

May we contact this employer?

 

Additional Professional References (if available)

If possible, list additional employers we can call. Or, list co-workers or others who know your work. Please do not duplicate references from above.

Supervisor, co-worker
or other
Business name/position
Years known
Phone
Supervisor, co-worker
or other
Business name/position
Years known
Phone
Supervisor, co-worker
or other
Business name/position
Years known
Phone
 

Personal References

Please do not list relatives as personal references, nor duplicate references from above.

Name
City and state
Relationship / years known
Phone
Name
City and state
Relationship / years known
Phone
Name
City and state
Relationship / years known
Phone

 

* REQUIRED INFORMATION

By clicking SUBMIT you certify that the information provided in this application is true and correct to the
best of your knowledge, and that you have read and agree to Davis In-Home Care, Inc. application terms.

 
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