Date: 9/03/2010

Application Form

American Companion Care
We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Office Location
Select Office Location:

Personal Information
First Name * Address 1 *
Last Name * Address 2
City *
State
Home Phone * Zip *
Work Phone Driver's License #
Mobile Phone
Email *

Section 1 - Personal Information
Number Question Effective Date Expiration Date
1 Can you legally work in the US: (required)  
  N/A N/A
2 Social Security Number:  
  (Numeric Answer Only) N/A N/A

Section 2 - Education/Credentials
Number Question Effective Date Expiration Date
1 Highest level of education completed: (Please include Year/Institution)  
  N/A N/A
2 Certified Nurse Aide/CNA (required)  
 
 
 
 
3 Home Health Aide/HHA (required)  
 
 
 
 
4 Other licenses held:  
  N/A N/A
5 Are all licenses current? (required)  
  N/A N/A

Section 3 - Job History
Number Question Effective Date Expiration Date
1 Do you have at least 1 year of experience in caregiving or a related field? (required)  
  N/A N/A
1a Previous Employer/Dates/Title/Responsibilities (required)  
 
1b Previous Employer/Dates/Title/Responsibilities (required)  
 
1c Previous Employer/Dates/Title/Responsibilities  
 
1d Previous Employer/Dates/Title/Responsibilities  
 

Section 4 - References
Number Question Effective Date Expiration Date
1 May we contact your 3 PROFESSIONAL REFERENCES provided below?  
  N/A N/A
1a Include Name, Phone number, and your association w/ each reference. (required)  
 
1b Include Name, Phone number, and your association w/ each reference. (required)  
 
1c Include Name, Phone number, and your association w/ each reference. (required)  
 

Section 5 - Other:
Number Question Effective Date Expiration Date
1 How did you hear about American Companion Care?  
 
 
 
 
2 If OTHER or CAREGIVER - please explain:  
 
3 Why would you be a great caregiver for one of our clients?  
 
4 Are you interested in working as a live-in caregiver? For example: 3 days on 4 days off.  
  N/A N/A
5 What is your avaliablity to work? (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.