Application for Home Care Providers

We are an equal opportunity employer. We do not discriminate in hiring, promotion, or other employment decisions on the basis of race, sex, color, pregnancy, religion, disability, age, veteran status, sexual orientation, marital status or any other basis protected by law. Equal access to programs, services and employment is available to all persons. I understand that any agreement between Community Bridges and myself is dependant upon the accuracy and truthfulness of the statements made in this application.

Personal

Name (Last, First, Middle) *

Who referred you? *

Street Address *

Telephone *

CIty, State, Zip Code *

E-Mail Address *

Desired Position *

Desired Starting Salary

Have you worked for Community Bridges before? *

Are you authorized to work in the U.S.? *(Proof of eligibility upon employment)

Do you have a valid driver's license? *

Can you Transport a disabled individual if the position requires it?

Can you travel if the position requires it?

Employment History
(Please list the most recent employer first)

1. Employer *

Address *

May we contact this employer? *

Telephone *

Name and title of immediate supervisor *

Job title and duties *

Final Wage *

Reason for leaving? *

Employment dates *(mm/yy - mm/yy)

Employer *

Address *

May we contact this employer? *

Telephoine *

Name and title of immediate supervisor *

Job title and duties *

Final wage *

Reason for leaving *

Employment dates *(mm/yy - mm/yy)

Employer *

Address *

May we contact this employer? *

Telephone *

Name and title of immediate supervisor *

Job title and duties *

Final wage *

Reason for leaving *

Employment dates *(mm/yy - mm/yy)

Education

Highest grade completed *

School/College *

City & State *

Diploma/Degree/Major *

Training relative to position

Employment Questionnaire

Please list three (3) expierences, skills or abilities relative to this position.

1. *

2. *

3. *

Is your home accessible to walkers or wheelchairs? *

Are you available 24/7 or prefer someone with a day program? *

Currently, who makes up your household? Check all that apply.

Spouse

Children

Please list the children's ages:

Extended Family

Please explain:

Pets

Please list types of pets:

Other

Please Explain:

Have you, or anyone in your household been convicted of a misdemeanor? *

If YES, please explain:

Have you, or anyone in your household been convicted of a felony? *

If YES, please explain:

Do you, or anyone in your household own firearms or weapons? *

If YES, please explain:

Do you find yourself to be more of a:

Leader

Follower

Teacher

Please explain your answer: *

Please descripe your home and any household rules, if applicable, to this position. Include informationabout potential allergens (pets, woodstoves,ect.) and neighborhood inviorment.

1. House Rules: *

2. Allergens: *

3. Neighborhood environment: *

Describe the type of person you would like to live with (Smoker, non-smoker, male, female, active, etc.) *

Are you willing to commit yourself in a home provider/roommate situation for at least one year? *

If a home provider/roommate position doesn't work out , are you interested in other programs? *

If YES, what programs are you interested in?

If YES, may we contact you at a later date?

Personal or Business References

(Do not include relatives or privously listed supervisors)

1. Name: *

Relationship: *

Years known: *

Telephone: *

Email: *

2. Name: *

Relationship: *

Years known: *

Telephone: *

Email: *

3. Name: *

Relationship: *

Years known: *

Telephone: *

Email: *

Notice: Background information and information pertaining to prior job preformance maybe obtained on all applicants.

In applying for employment with Community Bridges to by fully informed of my previous record and hereby authorize Community Bridges to refernce my background and to obtain any and all relevant information, which may concern me. I heareby release all persons, schools, companies, business, and law enforcement agencies from liability on account of furnishing such information.

I fully understand that any false anwsers or statements, misrepresentation of facts or omissions made by meon this application shall be suffcient cause for denial of employment or discharge and any off of employment is subject to satisfacory reference checks.

I fully understand that this employment application and any other company documents are not contracts of employment, and that any individual who is hired may voluntarily leave employment upon proper notice, and may be terminated by Community Bridges as authorized by Community Bridges policy and procedure manual.

I have read the above statement and agree to it's terms.

Applicant Signature: *(Please type your full name)

Date: *

This application for employment will be considerd active for 1 year from the above date. to be considered for emplyment after that time, you will need to submit another application.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

Family Support Council

Event Calendar

Application for Home Care Providers

Personal

Employment History (Please list the most recent employer first)

Education

Employment Questionnaire

Personal or Business References

Notice: Background information and information pertaining to prior job preformance maybe obtained on all applicants.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

Employment History
(Please list the most recent employer first)