Apply for In-Home Caregiver

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:In-Home Caregiver
ID:1037
Resume
Resume:
Supported formats: Word, PDF, RTF, Text, and HTML.
  - or Upload from:
 
Contact Information
* First Name:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone:
* Email:
Attachments
Cover Letter:
You can type in a Cover Letter or Copy/Paste from an existing document.
Applicant Questionnaire
* Do you possess a valid driver's license, automobile and auto insurance?
Yes
No
* Are you able to pass a background check?
Yes
No
* Are you able to pass a drug test?
Yes
No
* Are you able and willing to work at least 12 hours per week?
Yes
No
Do you have experience with caregiving?
Yes
No
* Are you eligible to work in the US?
Yes
No
Employment Application - Caregiver
Shepherd's Staff is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application process, he or she should inform a company representative.
* Applicant Name:
* Address:
* City, State, and Zip Code:
* Telephone Number:
* Email Address:
* How did you hear about this position?:
* Are you legally eligible to be employed in the US?:
Yes
No
* Are you 18 years of age or older?:
Yes
No
* Do you possess a valid driver's license, a reliable automobile, and auto insurance?:
Yes
No
* Are you able to pass a background check?:
Yes
No
* Are you able to pass a drug test?:
Yes
No
* Are you able and willing to work at least 12 hours per week?:
Yes
No
* Are you able and willing to travel up to 20 miles from your home for assigned shifts?:
Yes
No
* Are you able and willing to accept shifts within your availability from 1-12+ hours?:
Yes
No

Education and Training

* Last School Attended:
* Did you graduate?:
Yes
No
Subjects studies:
* Are you a licensed CNA, GNA or HHA in Maryland?:
Yes
No
* Are you a licensed CMT in Maryland?:
Yes
No

Employment History (Most Recent or Current Employer First)

* Company Name:
* Company Address (City & State):
* Phone Number:
* Job Title:
* Dates Employed:
* Duties:
* Supervisor:
* Reason for leaving:
* May we contact this employer:
Yes
No

Employment

Company Name:
Company Address (City & State):
Phone Number:
Job Title:
Dates Employed:
Supervisor:
Duties:
Reason for leaving:
May we contact this employer:
Yes
No

References (No Relatives)

* Name:
* Relationship:
* Phone Number:
* How long have you known this person?:
* Name:
* Relationship:
* Phone Number:
* How long have you known this person?:

Authorization & Signature

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 my 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)
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.
Submit
Cancel
ApplicantStack powered by Swipeclock