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Caregiver Application for Employment


Personal Information
Full Applicant Name:   Maiden Name (if any):
Current Address:   City:   State:   Zip:

Previous Address if less than 5 years at current address:
  City:   State:   Zip:

Social Security #:      Date of Birth:      Home Phone:

Cell Phone:             E-mail Address:


Emergency Contact
Contact Person Name:   Relationship:
Emergency Contact Home Phone:   Cell Phone:


Employment Information
Do you have at least (1) year experience with an agency or for a private individual, other than family of friends?
Yes     No

Are you available to work Weekends and/or Holidays?
No      Weekends      Holidays      Both


Shift Preference:       When can you start?


Select Availability:
 Mon.Tue.Wed.Thu.Fri.Sat.Sun.
Morning
Afternoon
Evening


Amount of wage now or last paid:      Desired hourly wage?


Briefly describe your experience as a caregiver below:


Do you have current CPR certification? Yes    No         Expiration date:

Have you ever had a TB skin test? Yes    No       If yes, when last?

Are you a legal citizen of the United States of America? Yes    No

Have you ever been convicted of a felony or misdemeanor? Yes    No

If Yes, please explain below:


Do you have your own reliable transportation? Yes    No

Do you have a valid driver's license? Yes   No    Driver's License #:     State:

Please Note: If hired, we will need a copy of your auto insurance and driver's license.


What areas of the Metro Detroit Area can and will you travel? Please list below.


Please describe your skills/strengths/what people like about you, which make you a good candidate to
be a Big Heart Caregiver:


Qualifications and Education
Do you have a GED or high school diploma? Yes   No

If yes, graduation year:       If no, what is the highest grade completed:

Did you attend college? Yes   No          If yes, where?

What curriculum?          Did you graduate? Yes   No

Are you attending college now? Yes   No

If yes, where?           What curriculum?

Why do you want to work for Big Heart?


Employment History
Company:           Dates:  to  

Address:          Phone:
Position:         Why did you leave?
Work Duties:

Supervisor Name:             May we contact? Yes   No



Company:           Dates:  to  

Address:          Phone:
Position:         Why did you leave?
Work Duties:

Supervisor Name:             May we contact? Yes   No



Company:           Dates:  to  

Address:          Phone:
Position:         Why did you leave?
Work Duties:

Supervisor Name:             May we contact? Yes   No


Professional References (no family members or friends)
Name:                               Phone:              How does this person know you? (Ex. co-worker, supervisor, etc.)     

Name:                               Phone:              How does this person know you? (Ex. co-worker, supervisor, etc.)     


Personal References
Name:             Relationship:

Address:          Phone:



Name:             Relationship:

Address:          Phone:


Certification and Release

By my signature placed below, I affirm the information provided in this employment application is true 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 if employed shall be considered sufficient cause for dismissal without any obligation or liability to me other than for payment, at the rate breach of trust while my job application is pending or during my period of employment, if hired.

I authorize Big Heart Senior Care to verify any and all information contained within this application including criminal history, including in the state of Michigan and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to relesase 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 authorize the investigation of all statements contained in this application including criminal history, including in the state of Michigan and motor vehicle driving records. I also authorize Big Heart Senior Care to contact my present employer (unless otherwise noted in this application form), past employers and listed references.



PLEASE TYPE YOUR NAME BELOW
Applicant's Signature:               Date:


Please fax a copy of your resume to (248) 928-9007
or email it to employment@bigheartsc.com.