Job Application

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Fields marked with an asterisk (*) must be filled out before submitting.

Personal Details

First Name *
Last Name *
Gender	Male Female
Date of Birth
Are you bilingual in any other languages? If so, what?

Contact Details

Address
City
Zip code
Email
Home Phone
Cell Phone
I am applying for a position as	An Hourly CNA An Hourly HHA An Hourly Caregiver A Home Care Aide
CNA, HHA, Home Care Aide Certification #
Referred by/source

Emergency Contact

Name
Phone Number
Relationship

Additional Details

Have you ever been convicted of a felony?	Yes No
Have you ever been convicted of a misdemeanor	Yes No
If yes to either, please provide details

Transportation

Do you have a California Drivers License?	Yes No
Drivers License #
Do you have dependable transportation?	Yes No
Number of hours you would like to work

Availability

Would you like a live-in situation? (3 or 4 days a week)	Yes No
Times you ARE available to work
Time NOT available to work
May we call you last minute in case of an emergency?	Yes No

Education

High School

Name
City/State
Dates Attended
Diploma earned	Yes No

College/University

Name
City/State
Degree Earned
Dates Attended

Other Schools

Name
City/State
Degree/Certification Earned

Credentials

CPR Certification	Yes No
Fire Safety Card	Yes No

Experience

Describe training or experience working with the elderly
What do you like the most about working with the elderly?
What do you like least about working with the elderly?

Skills

Please check all that you are experienced with	Companionship Bathing/Dressing Bathing/Full Assist Grooming Incontinence Transfer Assist Lifting Vacuuming Dusting Dementia Experience Alzheimer Experience Housekeeping Bed Linen Changes Laundry Grocery Shopping Cooking Driving Medication Reminders
What are your 3 greatest strengths?

Employment History

May we contact your current employer?	Yes No

Current Employer

Name of Company
Job Title
Duties
Pay Rate
Supervisor Name/Phone Number

Previous Employer

Name of Company
Job Title
Duties
Pay Rate
Supervisor Name/Phone Number
Dates Worked at Location

Employment/Work/Business References

1

Name
Company
Relationship
Years Known
Phone Number

2

Name
Company
Relationship
Years Known
Phone Number

Personal References

1

Name
City/State
Relationship
Years Known
Phone Number

2

Name
City/State
Relationship
Years Known
Phone Number
I certify that all information is true and complete. I understand that any misleading or incorrect statements render this application void and may be cause for termination. I herby authorize Affective Healthcare, Inc or its designees, to make such investigations and inquiries of statements contained in this application, of my driving record, employment history, educational background, and/or criminal conviction history as may be necessary in arriving at an employment decision and as otherwise authorized by applicable Federal and State laws. I hereby authorize past employers, public entities, schools, and references named herein to give information in responding to inquiries in connection with this application. I release said companies, public entities, schools or person from all liability for issuing this information relative to this application or any employment with Affective Healthcare, Inc.
	Yes No