A.V. Home With Love and Care, Inc.
Employment Application

Date:
Personal Information
First Name:
Last Name:
Address:
City:
State:		Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Daytime Telephone:
Evening Telephone:
Cellular Telephone:
Email:
Location Interested In:
Date of Birth:
State ID No:
Languages Spoken:
Do You Smoke?:		Yes No
Do You Have Allergy Problems?: If So, Describe		Yes No
Do You Take Medications?: If So, Describe		Yes No
Previous Employer Information
Previous Employer Name:
Previous Employer Address:
Previous Employer City:
Previous Employer State:
Previous Employer Zip Code:
Previous Employer Telephone:
Employment History: From/To (i.e.: 6/95 - 8/06)
Previous One on One Contact Name:
(Patient and/or Family Member)
Previous One on One Address:
Previous One on One City:
Previous One on One State:
Previous One on One Zip Code:
Previous One on One Telephone:
One on One History: From/To:
Education:
Institution Attended:
Major Subject:
Years Completed:
Other Information Required
Length of Caregiver Profession:
Length of One on One Care Service:
Length of Nursing Care Service:
Length of Convalescence Service:
Length of Board and Care Service:
Certifications (First Aid, CPR, CNA, HHA, RN, LVN, etc.):
Work In Live-In, Live-Out, Both?:
Work In Facility?:
Days Per Week Available?:
Preferred Working Days?:
Valid Driver’s License?: Yes/No?		Yes No
Car For Work Available?: Yes/No?		Yes No
Current Auto Insurance?: Yes/No?		Yes No
Car Registration Number?: Provide
Ever Convicted?:		Yes No
Felony/Misdemeanor (Non-Traffic)?: If So, Explain?:		Yes No
Last TB Scan Date?:
Last Physical Exam Date?:
Last Criminal Background Check?:
Last Fingerprint Live Scan Date?:

Have Duties and Experience In (Check Off)?:
Bathing/showering		Dressing/grooming		Alzheimer/dementia
Toileting		Blood pressure check		Blood sugar check
Incontinence		Hospice patients		Cooking (Western)
Medication supervision		G-tubes		Oxygen
Diabetes		Stroke patients		Parkinson’s patients
Bed & Tub Transfer		Hoyer Lift		Wheel Chair

We will also require you provide the following information:

• copy of your driver’s license or State ID
• copies of any license (CNA, LVN, etc.), fingerprinting, live-scan