Applicant Information
This is a two step process. The first step is below. The seond step with be on the next page where you will be asked to call or email to verify sending your application. We certify that the information you are submitting is strictly confidential and will be used only for consideration for employment .
Date Available:    
Last Name: First Name: Middle Initial:
Address1:
Address2:
City: State: Zip:
 
Phone: Mobile Phone:
Are you a QMAP? Yes   No Do you have dependable transportation? Yes   No
Are you a CNA? Yes   No Do you smoke? Yes   No
Do you have First Aid Cert? Yes   No Are you looking for Full time or Part time work? FT   PT Hours:
Do you have a current TB?: Yes   No    
 
A birth date and a Social Security Number is needed for a background check prior to hiring. This information will remain confidential,
Social Security:  Date of Birth: Month Day Year
 
Desired Salary:
Position Applied for:
Education
High School:
Address:
From: To:
Graduate? Yes No
   
Other School
Address:
From: To:
Graduate? Yes No
Degree:
References
Please list at least 3 professional references.
Name: Relationship:
Company: Phone:
Address:

 
Name: Relationship:
Company: Phone:
Address:
Name: Relationship:
Company: Phone:
Address:
Previoius Employment:
 
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary: Ending Salary:
Responsibilities:
Date Started: To:
May we contact your previous supervisor for a reference?Yes No
Company: Phone:
Address: Supervisor:
Job Title: Starting Salary: Ending: Salary:
Responsibilities:
Date Started To:
May we contact your previous supervisor for a reference?Yes No
 

By typing your name in the box below you are certifying your answers are true and complete to the best of your knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
Signature: Date Signed:
Interview Questions
1. Tell us about yourself.
(Background Experience: Why would you be best for the position?
 
2. Why should I hire you or what can you offer us that someone else can’t?
 
3. What is your greatest weakness?
 
4. What did you like best and least about your previous job?
 
5. What is your long-range objective? In five years I would...
 
6. How do you feel about caring for an elderly/disabled person? Or a person with memory problems?
 
7. Is there anything in the job description that you’re uncomfortable doing?
 
8. What is most important to you in a job?
 
9. Do you have knowledge and experience with cooking, and preparing meals for up to eight or more?
 
10. Do you have experience with house keeping skills such as cleaning, laundry, etc?
 
11. Are you a person who is able to multi-task and maintain organization?