Application Form

Office Location

Select Office Location

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 2 - Employment Position Applied For

I am applying for a position as a: (required)

How did you hear about employment opportunities at Hearts of Gold Caregivers? (required)

Have you previously applied, or worked for, Hearts of Gold Caregivers? (required)

Yes No

Please provide the names of any other home care agencies you have worked for.

Section 3 - Emergency Contact

Name (required)

Address (required)

Phone (required)

Section 4 - Transportation

Do you have a dependable vehicle to drive to and from work? (required)

Yes No

Section 5 - Availability

How many hours would you like to work per week? (required)

(Numeric Answer Only)

What days of the week are you available to work?

Are you available to work weekends? (required)

Yes No

Comments:

Show Plain Text

Section 6 - Education

Diploma/GED (required)

Yes No

College

City/State

Number of years completed

(Numeric Answer Only)

Other

City/State

Number of years completed

(Numeric Answer Only)

Degrees/Certification

Special skills or courses.

Show Plain Text

Section 7 - Experience

Discuss any training or experience you have working with the elderly or adults with disabilities (required)

Show Plain Text

Please give details of any current licenses (e.g. CNA, RN, Personal Care Aide)

Section 8 - Heart of Gold

Why do you think this job would be a good fit for you?

Section 9 - Criminal Background

Have you ever been convicted of a crime? (required)

Yes No

If yes, please provide details:

Show Plain Text

Section 10 - Employment History

COMPANY #1 (most recent employer)

May we contact your current employer? (required)

Yes No

Dates

Job title:

Reason left:

Duties:

Supervisor:

Phone:

COMPANY #2

Dates

Job title:

Reason left:

Duties:

Supervisor:

Phone:

Section 11 - Business Reference #1

REFERENCE #1 Name: (required)

Address: (required)

Relationship: (required)

Years known: (required)

(Numeric Answer Only)

Phone: (required)

Section 12 - Business Reference #2

REFERENCE #2 Name: (required)

Address: (required)

Relationship: (required)

Years known: (required)

(Numeric Answer Only)

Phone: (required)

Section 13 - Signature & Certification

I agree to abide by the Driver Safety Protocol of Hearts of Gold Caregivers. (required)

Yes No

I will provide and maintain curent proof of auto insurance that complies with state requirements for financial responsibility (required)

Yes No

I agree to hold a valid/current Drivers license for the state of primary operation of my motor vehicle, and will provide a copy to the office (required)

Yes No

I understand that being impaired or under the influence of legal or illegal drugs or alcohol whilst working is prohibited. If company policy requires, I am willing to submit to testing to detect the use of illegal drugs or alcohol prior to and during employment. (required)

Yes No

Section 14 - Supporting/Additional comments to the application

Use the following space to clarify any of the answers you have given above.

Show Plain Text

Section 15 - Electronic signature and date

By providing the electronic signature below, I certify the following: I am aged 18 or older. I understand that any offer of employment is contingent upon a satisfactory criminal background check, which I hereby consent to. I further consent to drug and alcohol screening both prior to and during employment, and agree to a no-smoking policy during ALL working hours. (required)

Yes No

I certify that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentation of facts may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents to verify any information including, but not limited to, criminal history and motor vehicle records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background, and I hereby release all such agencies and their representatives from any liability for any damage whatsoever for issuing such information. (required)

Yes No

Sign (electronic signature): (required)

Date: (required)

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above. PLEASE NOTE: If you're unable to complete this application or need it an alternate version, please call our office(s): 541.387.0207. You may also email us at: SC@heartsofgoldcaregivers.com for assistance. Thanks for your interest.

Signature

Hearts of Gold Caregivers Application Form

Office Location

Personal Information

Section 2 - Employment Position Applied For

Section 3 - Emergency Contact

Section 4 - Transportation

Section 5 - Availability

Section 6 - Education

Section 7 - Experience

Section 8 - Heart of Gold

Section 9 - Criminal Background

Section 10 - Employment History

Section 11 - Business Reference #1

Section 12 - Business Reference #2

Section 13 - Signature & Certification

Section 14 - Supporting/Additional comments to the application

Section 15 - Electronic signature and date