Apply for Personal Care Attendant (Caregiver)

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Summary
Title:Personal Care Attendant (Caregiver)
ID:1001-A
Location:Indianapolis, IN
Salary Range:$13-$16/ hour
Resume
Resume:
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Contact Information
* First Name:
* Last Name:
* Social Security Number:
* Date of Birth:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Application Information
Source:
description for the source field
Referred By:
Enter the name of the current staff member or client referring you to this position
Opt-In Confirmation
I authorize recruiters from Graceful Aging Home Care to send text messages from 8667024319 with requests for additional information in relation to this job application only. Message/data rates apply. Message frequency varies.
Attachments
Cover Letter:
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Application for Employment
PERSONAL INFORMATION
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EXPERIENCE

PREVIOUS CAREGIVER EXPERIENCE #1

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PREVIOUS CAREGIVER EXPERIENCE #2

Yes   No

PREVIOUS CAREGIVER EXPERIENCE #3

Yes   No

PREVIOUS CAREGIVER EXPERIENCE #4

Yes   No

PREVIOUS CAREGIVER EXPERIENCE #5

Yes   No
REFERENCES

Professional References (do not include family or friends)

Reference 1

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Reference 2

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Reference 3
CRIMINAL HISTORY
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ABUSE INVESTIGATION
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EDUCATION

Give record of all High Schools, Colleges, Universities and Vocational/Technical Schools you have attended.

School 1

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School 2

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School 3

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High School

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SPECIALIZED TRAINING
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AVAILABILITY OF WORK
  
  
  
  
  
  
  
  
  
  
  
  
  
SKILLS AND PREFERENCES
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
WORK RESTRICTIONS
TRANSPORTATION
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Private Vehicle   Bus   Bike   Other   N/A
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ADDITIONAL QUESTIONS
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EMERGENCY CONTACT INFORMATION

EMERGENCY CONTACT #1

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EMERGENCY CONTACT #2

EMERGENCY CONTACT #3
AUTHORIZATION

The facts set forth in this application and any supplemental information are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be considered sufficient cause for immediate discharge. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for the company to hire me. If I am hired, I understand that either the company or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of the company has the authority to make any assurance to the contrary.

I understand that I am required to abide by all rules and regulations of the company.

Equal Opportunity Employment
We are an Equal Opportunity employer and do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, national origin, medical condition, disability, veteran status, or any other basis protected by law.

The information provided will be used for research, reporting, statistical purposes and to monitor legal compliance. To help us comply with these government requirements, please complete the following information.

Completion of this form is voluntary and will not affect your opportunity for employment or terms or conditions of employment if hired. We appreciate your cooperation.
Gender:
Female
Male
I Choose Not to Respond
Race/Ethnicity:
American Indian or Alaska Native (Not Hispanic or Latino)
A person having origins in any of the original peoples of North America and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino)
A person having origins in any of the Black racial groups of Africa
Hispanic or Latino
A person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
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
I Choose Not to Respond
Veteran Status: (Please check all that apply)
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.
War/Campaign/Expedition Veteran
A veteran who served on active duty in the U.S. military, ground, naval or air service during a war or in a campaign or expedition for which a campaign badge has been authorized.
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.
I Choose Not to Respond

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.
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