Caregiver Employment Application Caregiver Employment Application By completing this application and questionnaire, you are applying for employment at Caring Doves Home Care Service, LLC. Caring Doves is an equal opportunity employer. We are dedicated to a policy of non-discrimination of applicants for any reason including race, color, age, sex, religion, disability, medical condition, national origin, sexual orientation, or marital status. Job Applicant Contact Info Name First Middle Last Last Email Daytime Phone Evening Phone Mobile Phone * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal How did you hear about Caring Doves? Caring Doves Client Friend Social Media Flyer / Brochure Web Search Website Online Job Site Other If Other Selected Above, Please Explain Availability Counties You Are Willing to Work in? * Bollinger Butler Cape Girardeau Dunkin Iron Madison Mississippi New Madrid Pemiscot Perry Scott St. Francois St. Genevieve Stoddard Wayne Cities You Are Willing to Work in? * Advance Benton Bernie Bloombfield Bloomsdale Campbell Cape Girardeau Caruthersville Chaffee Charlesto Clarkton Dexter East Prairie Farmington Fredricktown Greenville Hayti Ironton Jackson Kennett Malden Marble Hill Matthews Morehouse New Madrid Oran Park Hills Perryville Piedmont Pilot Knobb Poplar Bluff Portageville Puxico Scott City Senath Sikeston St. Genevieve Steele Employment Desired Full-time Part-time Full- or Part- time Desired Shift * Daytime - 7 am - 4 pm Evenings - 4 pm- 11 pm Nights - 11 pm - 7 am Approx. Hours Available Per Week Days Available * Monday Tuesday Wednesday Thursday Friday Saturday Sunday Are you willing to be On Call or Called in to Work for Unexpected Emergencies? * No Yes Job Applicant Details Are you over the age of 18 years? * Yes Authorized to Work in the U.S. * Yes Languages Your Are Fluent In * English Spanish Other Other Languages? Are you able to lift up to 50 lbs.? * No Yes Did you use illegal drugs? * Yes No Have you ever been convicted of a misdemeanor or a felony crime? * No Yes If yes checked above, please provide details. If employed by Caring Doves, I agree not to smoke or use tobacco products during work hours, except on breaks and in designated locations specified by employer or in company vehicles. * No Yes Most clients require transportation, often using the Care Provider's vehicle. Therefore, we need some general information about your vehicle and if you have a valid license. In the event you are offered a position with Caring Doves, we will be requesting additional information to verify you have an active insurance policy on your vehicle. Do you have dependable transportation? * No Yes Make / Model of your vehicle? License Plate# Do you have a valid driver's license * Yes No If employed by Caring Doves, I agree to provide insurance and licensing information relating to my vehicle. * No Yes Education Schools / Colleges / Universities * High School Graduate/GED Attended Community College / No Degree 2-Year Associates Degree Attended 4-Year College / University / No Degree 4-Year College Degree Special Skills / Courses? (List any scills that may assist in Certifications? (Certified Nursing Assistant, CPR, etc.) Degrees / Certificates - A copy of all Degrees / Certificates must be provided and will be verified with the issuer. Upload Copies of Degrees/Certifications Here Drop a file here or click to upload Choose File Maximum file size: 134.22MB Skills & Experience Are you currently employed to provide Care for others? * No Yes Have your previously worked as a Care provider? * No Yes What do/did you like most about working as a Care provider? What do/did you like least about working as a Care provider? Describe your past duties and experience Upload Resume Drop a file here or click to upload Choose File Maximum file size: 134.22MB Select any skills or care you are prepared to provide: * Any Alzheimers-Dementia Diabetes Parkinsons ALS Arthritis MS Disabilities Cancer Chronic Illness Post-Surgical Injuries Neuromuscular Medication Reminders Transportation Bathing (Regular, bed or sponge) Meal Preparation Feeding Dressing/Grooming Incontinence Light Housekeeping Ambulation Transfer Assist Laundry Conversation Reading Assist Letter Writing Oral Care Shaving Assistance Assist with P.T. /Exercise Computer Use Social Activites Prosthesis Assist Hobbis Assist Finances Assist Pre/Post Labor Companion Care & Safety Hospice Pet Care Assist Childcare Home Checks Work History Job Title * From * To * Start Pay $ Ending Pay $ Company * Supervisor's Name Company Phone Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Click the + Add Button Below to Add More Work History plus1 Add minus1 Remove Business / Professional Character References Caring Doves requires at least three business or professional references and two character references. References should not be family, friends or peers. Name Relationship Former SupervisorFormer Coworker-ColleagueClients (home care, babysitting, housekeeping)TeacherAdvisorVolunteer Organization Yrs. Known Phone Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Click the + Add Button Below to Add More References Captcha plus1 Add minus1 Remove Submit If you are human, leave this field blank.