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If yes, please explain including disposition (fines, probation, jail, etc)
Have you read and understood the Applicant Fact Sheet?
Please List your most recent 4 employers, starting with the most recent, up to 10 years.
Date of Employment - Start
Date of Employment - End
Name of Employer
Phone Number of Supervisor
Reason For Leaving
May we contact this employer?
If "No", why?
Name of Institution
Address of Institution
Type of Diploma/Degree
Did You Graduate?
Last Year Attended
Have you applied for referral or been referred by Home Care & Companions in the past?
If yes, please indicate date:
Home Care & Companions has clients throughout central Nebraska. Please indicate which areas you are willing to travel to:
Grand Island & surrounding communities
Hastings & surrounding communities
Kearney & surrounding communities
If other, please list locations:
Caregiving Experiences/ Training/ Certificates/ Other Skills:
Can you assist with lifting a client with their assistance?
Can you assist with lifting a client without their assistance?
Can you assist with bathing?
If no to any of the above, please explain:
Will you care for:
Do you have experience with the following dietary requirements:
Please list if others:
Tell me a little bit about your food preparation experience:
What homemade foods can you prepare?
What packaged foods?
Do you use packaged foods only?
If your client needed this type of cleaning, what would you expect to do?
What are your personal and professional goals?
Do you have a reliable vehicle?
Valid driver’s license?
Will you work around pets?
If no, please explain:
Do you have work restrictions/limitations you feel we should be aware of?
If yes, please explain:
What date are you available to begin work with a client?
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Thank you for your employment application.
We appreciate your interest in Home Care & Companions. Your application has been submitted for review. If we find that your qualifications match our openings, we will contact you soon.