M & O Polish Home Care Services

Personal Information Part 1

Name

Last Name

Street Address

City

State / Province

Zip Code

Country

Phone

Personal Information Part 2

Are you a USA citizen?Are you a USA citizen?YesNo

Work preferenceWork preferenceElder CareHousekeepingDisability Care

Other work experience

List past experienceList past experienceElder CareHousekeepingDisability CareOther

Other past work experience

Other certification

Other experience

List allergiesList allergiesDogsCatsBirds

Other allergies

Do you have dependable transportation?Do you have dependable transportation?YesNo

Do you have a drivers license?Do you have a drivers license?YesNo

List languages you speak

Other Comments

Availability – Part 2

Days and times not available

Can you be called at the last minute in case of emergency?Can you be called at the last minute in case of emergency?YesNo

Education

High School

City/State

mm/dd/yyyy

College

City/State

mm/dd/yyyy

Training and skills

Discuss any training or experience working with the elderly. How are you trained and/or experienced in working with the elderly?

What do YOU do that shows and proves you’re Reliable, Trustworthy and Honest?

What would you like least about working with the elderly?

Employment History.

Company Name

mm / dd /yyyy

Job Title

Reason for leaving

Duties

Supervisor

Supervisor Phone Number

Company Name

Employed From (mm / dd / yyyy)

Employed To (mm / dd / yyyy)

Job Title

Reason for leaving

Duties

Supervisor

Supervisor Phone Number

Company Name

Employed From (mm / dd / yyyy)

Employed To (mm / dd / yyyy)

Job Title

Reason for leaving

Duties

Supervisor

Supervisor Phone Number

Company Name

Employed From (mm / dd / yyyy)

Employed To (mm / dd / yyyy)

Job Title

Reason for leaving

Duties

Supervisor

Supervisor Phone Number

Why Do You Feel You Would Be An Excellent Addition to Our Team?

Business – Professional References

First Name

Last Name

Address

City

State

Zip Code

Country

Years/known

Phone Number

First Name

Last Name

Address

Zip Code

Country

Years/known

Phone Number

First Name

Last Name

Address

Zip Code

Country

Phone Number

Do you have a resume you would like to send?Do you have a resume you would like to send?YesNo

Emergency Contact

First Name

Last Name

Address

City

State

Zip Code

Country

Relationship

I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith.I understand that if I knowingly make any mistatements of fact, I am subject to disqualification, dismissal, or other action pursuant to employment agency policy and proceedure, and subject to criminal penalties as prescribed by law.

Electronic Signature

First Name

Last Name

Date (mm / dd / yyyy)

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