Application Form

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - How did you hear about us?

Please select how you heard about us. (required)

Section 2 - Position & Availability

What position are you applying for? (required)

Hours you are available (required)

Times Not Available (required)

Are you available for emergencies? (required)

Yes No

Hourly Wage Desired (required)

Are you eligible to work in the US? (required)

Yes No

Visiting Angels is a 24/7 operation. Weekend work is a requirement. By initialing here, you are acknowledging that you can and will accept weekend assignments

Section 3 - Transportation

All Caregivers must have reliable transportation. What form of transportation do you use to get to and from work? (required)

Some caregiving positions require driving for work. Are you willing to accept a position that requires driving for work? (required)

Yes No

If yes, do you have a valid license?

Yes No

State

Number

Do you have proof of insurance? (required)

Yes No

Section 4 - Education

High School - City/State

College - City/State

Other - City/State

Degree/certification

Section 5 - Experience

Discuss any training or experience you've had with the elderly (required)

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What do you enjoy most about working with the elderly? (required)

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What do you like the least about working with the elderly? (required)

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Section 6 - Criminal History

Have you ever been convicted of a felony or misdemeanor? Note: A criminal conviction is not an automatic bar to employment. The nature of the offense, the date of conviction, the position applied for and other factors will be considered during the hiring process. (required)

Yes No

If yes, state the offense convicted of, date of the conviction and jurisdiction

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Section 7 - Emergency Contact Information

Name/Relationship (required)

Contact Information (Phone Number) (required)

Section 8 - Employment-1-years hands-on experience required.

Most Recent Employer - Personal Care Experience only. (required)

May we contact your current employer? (required)

Yes No

From/To (required)

Job Title (required)

Reason for leaving? (required)

Duties (required)

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Supervisor

Phone number (required)

Company- Personal Care Experience only.

From/To

Job Title

Reason for leaving?

Duties

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Supervisor

Phone number

Company- Personal Care Experience only.

From/To

Job Title

Reason for leaving?

Duties

Show Plain Text

Supervisor

Phone number

Section 9 - Certification and Release

I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions or misrepresentation of fact will result in rejection of this application and/or discharge at any time during employment. I authorize Olson Homecare, LLC dba Visiting Angels to verify and and all information contained within this application, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies & law enforcement authorities to release any information concerning my background & hereby release any said persons, schools, companies & law enforcement authorities from any liability for any damage whatsoever for issuing this information. (required)

Yes No

Section 10 - Drug Test

I understand that the use of illegal drugs is prohibited during employment and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment. (required)

Yes No

Section 11 - Non-Compete

I understand that if hired I will be required to enter into a non-compete agreement, which will limit my ability to perform caregiving work for certain clients or otherwise work for a competing business after seperating from Olson Homecare, LLC dba Visiting Angels. (required)

Yes No

Section 12 - Applicants Signature

Applicants Signature (required)

Social Security Number (required)

Date (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.

Signature

Visiting Angels Application Form

Personal Information

Section 1 - How did you hear about us?

Section 2 - Position & Availability

Section 3 - Transportation

Section 4 - Education

Section 5 - Experience

Section 6 - Criminal History

Section 7 - Emergency Contact Information

Section 8 - Employment-1-years hands-on experience required.

Section 9 - Certification and Release

Section 10 - Drug Test

Section 11 - Non-Compete

Section 12 - Applicants Signature