Application

Allevia Home Care

"*" indicates required fields

1General Contact Info

2Transportation

3Emergency Contact Info

4Positions And Availability

5Education

6Skills (Languages)

7Criminal History

8Employment History

9References

First Name*

Middle Name

Last Name*

Date Of Birth*

MM slash DD slash YYYY

Gender*

Male

Female

Other

Ss#:*

Address City State / Province / Region ZIP / Postal Code

Email*

Home Phone

Cell Phone*

Are You Eligible To Work In The USA?*

Yes

Are You Legal US Citizen?*

Yes

Transportation

Some Caregiving positions require a valid driver's or a car, including valid insurance coverage

Do You have a Valid Driver's License?*

Yes

State*

License*

Do You have a Car?*

Yes

Make & Model*

If Yes, Do You Have Valid Insurance ?*

Yes

Proof Of Insurance

Max. file size: 2 GB.

Positions And Availability

I 'M Applying for a Position As:*

Hours You're Available*

1-4 Hours

5-8 Hours

9-12 hours

Schedule Desire*

Mon

Tue

Wed

Thur

Fri

Sat

Sun

Time Available*

Morning

Evening

Overnight

Are you Available For Emergencies?*

Yes

Are you Available For 24hr Live-in Position?*

Yes

3 Days

4 Days

5 Days

Education

High School*

City/State*

Degree*

Year*

College

City/State

Degree

Year

Other

City/State

Degree

Year

Degree/Certification

Skills (Languages)

Check All Languages You Speak*

English

Mandrin

Japanese

Somali

French

Hindi

German

Chinese

Spanish

Portuguese

Turkish

Bengali

Arabic

Russian

Swahili

Other

Place a Check By The Conditions or Duties You Have Experienced In:*

Bathing / Showering

Bed-Bath

Oral Hygiene

Dressing

Toileting

Bedpan

Skin Care

Shaving

Ambulating

Transferring

Transportation

Hospital Bed

Shower Chair

Wheel Chair

Hoyer Lift

Gate Lift

Food Preparation

Meal se

Nutrition Training

Eating Assistant

Bed Linen Change

Laundry

Dusting

Light House

Medication Assistance

Combative

Bed Bound

Dementia

Parkin's

Paralyzed

Diabetes

Cancer

Criminal History

Have You Ever Been Convicted Any Feloney or Misdesmeanor?*

Yes

If Yes Explain or N/A*

Employment History

List below last three employers, starting from the most recent/current one first

Current Employer?*

Yes

May We Contact Your Current Employer?*

yes

Company*

Hired Date*

MM slash DD slash YYYY

Left Date*

MM slash DD slash YYYY

Job Title*

Reason For Leaving*

Supervisor*

Phone Number*

Duties*

Current Employer?

Yes

May We Contact Your Current Employer?

Yes

Company

Hired Date

MM slash DD slash YYYY

Left Date

MM slash DD slash YYYY

Job Title

Reason For Leaving

Supervisor

Phone Number

Duties

Current Employer?

Yes

May We Contact Your Current Employer?

Yes

Company

Hired Date

MM slash DD slash YYYY

Left Date

MM slash DD slash YYYY

Job Title

Reason For Leaving

Supervisor

Phone Number

Duties

References

List at Least 2 references "Family not included".

Refrences Name*

Title*

Organization*

Email*

Phone*

Relationship*

Refrences Name

Title

Organization

Phone

Relationship

Refrences Name

Title

Organization

Phone

Relationship

Sign & Certify

Allevia Home Care does not discriminate in their hiring practices or in any other decision on the basis of race, color, sex, sexual orientation, citizenship, national origin, veteran status, age and/or physical or mental disability unrelated to the ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

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 of this application and/or discharge at any time during employment. I understand that Allevia Home Care LLC is under no obligation to consider or reconsider this application at any time, and that acceptance of this application does not constitute an offer of employment.

I authorize “Allevia” to verify any and all information contained within this application, educators, employers, references, consumer credit, private or government agencies and any other individuals who may have knowledge of me or my work experience. I authorize all persons, schools, companies & law enforcement authorities to release any information concerning my background & hereby release any said persons, schools, companies & law enforcement authorities from any liability for any damage whatsoever for issuing this information.

I agree to cooperate with such an investigation and release all parties from any and all liability, claims or damages, directly or indirectly, resulting from furnishing such information. I also understand that the use of illegal drugs is prohibited during employment and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment.

Restrictive Covenant: I agree not to do business directly with any individual or business entity that Allevia Home Care LLC. has introduced to me or by entering into employment with such individuals or businesses.

Signature

Required

Applicant Name*

Applicant Name:

Applicant Date*

MM slash DD slash YYYY

Allevia Home Care

Transportation

Positions And Availability

Education

Skills (Languages)

Criminal History

Employment History

References

Sign & Certify

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