Caregiver Application - Weekends Only | Compassionate Personal Care Services, LLC

Date of Application *

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone / Cell Phone *

Email Address *

Have you ever applied for employment or been employed with us before? *

Yes
No

Do you require an accommodation to perform the tasks on the job description? *

Yes
No

Who referred you to this company? *

Employment Service
Friend/Relative
Online
Other

Have you ever been convicted of a felony? *

Yes
No

Do you have any criminal charges pending? *

Yes
No

I understand that my employment with CPCS is contingent on having no conviction appearing on my police record check, that substantially relates to the circumstances of the position. A criminal record does not constitute an automatic bar to employment. *

Yes

As a Personal Care Worker (PCW), a drug test must be taken and all immunizations must be updated. Do you agree? *

Yes
No

Do you have a valid driver's license? *

Yes
No

Do you have reliable transportation? *

Yes
No

Do you have car insurance? *

Yes
No

Are you currently employed? *

Yes
No

Date available to start work with CPCS *

The job posting is for weekends only. Will you be able to work weekends? *

Please indicate how many years of experience do you have with clients who have Down Syndrome or Dementia. *

Education

Please provide your attendance or graduation from High Schoool or Technical College *

Employment History

Current or Previous Employer *

Date of Employment (From – Until) *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Telephone *

Name of Supervisor *

Position and Responsibilities *

Previous Employer *

Date of Employment (From-Until) *

on the you

Reason for Leaving *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Telephone *

Name of Supervisor *

Position and Responsibilities *

Previous Employer *

Date of Employment (From-Until) *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Telephone *

Name of Supervisor *

Position and Responsibilities *

Captcha – To Verify You Are Human *

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