Date: 4/23/2014

Application Form

Loving Companions Senior Services

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.

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 - General Information

Number Question Effective Date Expiration Date
1. Can you provide a copy of your driver's license at the point of hire? (required)  
     
2. Drivers License Expiration Date:  
     
3. Social Security #  
  (Numeric Answer Only)    
4. Can you provide a copy of your SS card at the point of hire? (required)  
     
5. Date of Birth:  
     
6. Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? (required)  
     
7. If yes, please explain.  
 
8. Would you be willing to undergo a background check? (required)  
     
9. Position Applying For: (required)  
     

Section 2 - Transportation

Number Question Effective Date Expiration Date
1. Do you have dependable transporation? (required)  
     
2. Year, make, and model of your vehicle (required)  
     
3. License plate # (required)  
     
4. Auto insurance policy # (required)  
     
5. Auto insurance expiration date  
     
6. Insurance company (required)  
     
7. Insurance agent name  
     
8. Insurance agent phone #  
     
9, Can you provide documentation of your auto insurance? (required)  
     

Section 3 - Availablity

Number Question Effective Date Expiration Date
1. Number of hours you would like to work (required)  
 
 
 
 
2. Times available to work (required)  
     
3. Any time NOT available to work (required)  
     
4. Can you be called last minute in case of an emergency? (required)  
     
5. Other comments on your availablity  
 

Section 4 - Employment Verification

Number Question Effective Date Expiration Date
1. Are you a U.S. citizen? (required)  
     
2. If you are not a U.S. citizen, please indicate VISA type and number.  
     
3. Are you authorized to work in the U.S.? (required)  
 
 
 
 

Section 5 - Education

Number Question Effective Date Expiration Date
1. Name of High School: (required)  
     
2. Location of High School: (required)  
     
3. Did you graduate? (required)  
     
4. Years Attended (From/To): (required)  
     
5. Additional Education (vocational, undergraduate, etc.)  
     
6. If yes, please list the name of the school and years attended (From/To)  
 

Section 6 - Other Training: Certifications/Licenses

Number Question Effective Date Expiration Date
1. Certifications/Licenses:  
 

Section 7 - Experience

Number Question Effective Date Expiration Date
1. Discuss any training or experience working with the elderly  
 
2. What do you like the most about working with the elderly?  
 
3. What do you like least about working with the elderly?  
 

Section 8 - Skills: Pls mark tasks you have done for seniors

Number Question Effective Date Expiration Date
1. Companionship  
     
2. Bathing/Dressing  
     
3. Grooming  
     
4. Incontinence  
     
5. Transfer assist  
     
6. Vacuuming  
     
7. Dusting  
     
8. Clean bathroms  
     
9. Clean kitchen  
     
10. Ben linen changes  
     
11. Laundry  
     
12. Grocery shopping  
     
13. Cooking  
     
14. Driving  
     
15. Medication reminders  
     

Section 9 - Current Employment

Number Question Effective Date Expiration Date
1. Current Employer:  
     
2. Address:  
     
3. City:  
     
4. State:  
     
5. Zip Code:  
     
6. Start Date:  
     
7. End Date:  
     
8. Hours Worked:  
 
 
 
9. Position/Title:  
     
10. Describe Your Responsibilities:  
 
11. Supervisor's Name/Title:  
     
11. Supervisor's Phone:  
     
13. Reason for Leaving:  
 
14. May we contact?  
     

Section 10 - Employment History - Part One

Number Question Effective Date Expiration Date
1. Last Employer:  
     
2. Address:  
     
3. City:  
     
4. State:  
     
5. Zip Code:  
     
6. Start Date:  
     
7. End Date:  
     
8. Hours Worked:  
 
 
 
9. Position/Title:  
     
10. Describe Your Responsibilities:  
 
11. Supervisor's Name/Title:  
     
12. Supervisor's Phone:  
     
13. Reason for Leaving:  
 
14. May we contact?  
     

Section 11 - Employment History - Part Two

Number Question Effective Date Expiration Date
1 Last Employer:  
     
2 Address:  
     
3 City:  
     
4 State:  
     
5 Zip Code:  
     
6 Start Date:  
     
7 End Date:  
     
8 Hours Worked:  
 
 
 
9 Position/Title:  
     
10 Describe Your Responsibilities:  
 
11 Supervisor's Name/Title:  
     
12 Supervisor's Phone:  
     
13 Reason for Leaving:  
 
14 May we contact?  
     

Section 12 - Reference 1

Number Question Effective Date Expiration Date
1. Name: (required)  
     
2. Company: (required)  
     
3. Phone:  
     

Section 13 - Reference 2

Number Question Effective Date Expiration Date
1. Name: (required)  
     
2. Company: (required)  
     
3. Phone:  
     

Section 14 - Reference 3

Number Question Effective Date Expiration Date
1 Name: (required)  
     
2 Company: (required)  
     
3 Phone:  
     

Section 15 - Reference 4

Number Question Effective Date Expiration Date
1 Name:  
     
2 Company:  
     
3 Phone:  
     

Section 16 - Reference 5

Number Question Effective Date Expiration Date
1 Name:  
     
2 Company:  
     
3 Phone:  
     

Section 17 - Reference 6

Number Question Effective Date Expiration Date
1 Name:  
     
2 Company:  
     
3 Phone:  
     

Section 18 - Emergency Contact Information

Number Question Effective Date Expiration Date
1. First Name: (required)  
     
2. Last Name: (required)  
     
3. Address:  
     
4. City:  
     
5. State:  
     
6. Zip Code:  
     
7. Phone 1: (required)  
     
8. Phone 2:  
     
9. Relationship: (required)  
     

Section 19 - Miscellaneous

Number Question Effective Date Expiration Date
1. Cell phone # (required)  
     
2. Recieve text messages? (required)  
     
3. Cell phone company/provider (required)  
     
4. Please list any disabilities or injuries that may affect your job performance (e.g. chronic back pain):  
     
5. Please list any phobias you have that may affect your job performance (e.g. fear of dogs):  
     
6. How/Where did you learn about this job position? (required)  
     

Section 20 - Resume

Number Question Effective Date Expiration Date
1 You Must Email or Fax Your Resume to: (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.