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Background Information
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Name
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Address
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City
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Zip Code
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State
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DOB
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Cell Phone
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Home Phone
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Email
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Do you own a car?
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Yes No
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Education
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Graduation Date
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Location
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Name of High School
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Graduation Date
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Location
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Major
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Name of College
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Graduation Date
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Location
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CNA Training School
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Are you trained in CPR?
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Do you have a medication certificate?
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Yes No
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Are you trained in First Aid?
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Yes No
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Yes No
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Work History
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Include the name of employer, address,phone number, name of supervisor, dates of
employment, salary, job title,the reason for leaving and list the specific duties performed.
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May we contact your previous employers?
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References
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List three references other then relatives or employers. Include name, work position,
phone number and years of acquaintance
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Job Preference
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Why are you suitable for a
caregiver/nanny position with us?
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What position are you applying for? (select all that apply)
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Elder Care
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Mother's Helper
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Errands
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Work Availability (select all that apply)
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Part-Time
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Full-Time
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Live-Out
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Live-In
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Weekends
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Days
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Evenings
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Over-Nights
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Do you any special skills that you can share with
children or seniors? (language, art, craft, etc.)
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What are your views/methods
of disciplining children?
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Health Information
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Do you have any mental, physical limitations? If yes explain
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Are you updated on your shoots?
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Do you smoke?
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Yes No
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Yes No
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Married
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Single
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Person to contact in case of emergency
with phone number
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Have you ever been convicted of a crime? Explain
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How were you referred to Loving Home Care
friend, newspaper, etc. state the name
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Additional Comments
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Today's Date
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SUBMIT ONLY ONCE
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