Driver's License Home Care
Resume:
Caregiver Employment Application
Employee Information
Employment History
Please list your last 3 jobs, starting with the most recent. NAME
Jonathan
First Name
Middle Name
Grant
Last Name
What name do you go by? (if different than First Name) CONTACT INFORMATION
Do you have access to a GPS capable and web-enabled smartphone? DEMOGRAPHICS
**********@*****.***
Email Address
Select one:
Yes No
Mobile Phone Number
Home Phone Number
(Age 36)
Birth Date
Aug 8 1988
438658425
Social Security Number
HOME ADDRESS
DRIVER'S LICENSE VERIFICATION
I hereby voluntarily consent to and authorize Leading Home Care to obtain a report verifying the validity of my driver’s license, and I authorize all persons and organizations that may have information relevant to this research to disclose such information.
622 Sycamore Ln
Street Address
Apartment, suite, etc.
Monroe
City
Louisiana
State
71202
Zip Code
Do you have a valid Driver's License?
Yes No
Driver's License Number
DL Issue Date
Mon Day Year
DL Expire Date
Mon Day Year
Driver's License State
Select one:
Yes No
Emergency Contact Information
EMERGENCY CONTACT #1
I authorize my employer to contact this person in case of a known or suspected emergency.
David Murrell
Name
Father
Relationship
Phone Type
Agree?
Yes No
Voluntary Disclosures
As an employer, we are subject to certain federal reporting requirements as it relates to civil rights laws and regulations. In order for Leading Home Care to comply with these laws and regulations, we collect and share workforce data with authorized government agencies. Your decision to self-identify your race/ethnicity and/or gender is strictly voluntary and in no way impacts our hiring decisions. If you choose not to self-identify, you will not be subject to any adverse treatment. This information will be maintained by Leading Home Care in accordance with all applicable laws and regulations, and will remain confidential.
Race/Ethnicity: Select the option that applies.
Male
Female
Please select your Gender.
Black or African American – Not Hispanic or Latino Race/Ethnicity
Are you currently employed?
Yes No
Grant, Jonathan Caregiver Employment Application
Education & Training
HIGH SCHOOL
COLLEGE / TECHNICAL PROGRAM #1
COLLEGE / TECHNICAL PROGRAM #2
OTHER SPECIAL TRAINING OR SKILLS
Employment Questionnaire
PREVIOUS JOB #1 (MOST RECENT / CURRENT)
PREVIOUS JOB #2
Cognitive Development
Company Name
Dsw
Job Title
10/10/2016-4/17/2022
Dates Worked (Start & End Date)
Client passed
Reason For Leaving
$10
Pay Rate
Mohawk Traven
Company Name
Bus boy/oyster
Job Title
8/12/2023-11/5/2023
Dates Worked (Start & End Date)
Not enough hrs
Reason For Leaving
$10
Pay Rate
PREVIOUS JOB #3
YEARS OF EXPERIENCE
HOBBIES & INTERESTS
Company Name
Job Title
Dates Worked (Start & End Date)
Reason For Leaving
Pay Rate
7
Number of years of caregiving experience?
Please list a few of your hobbies & interests.
Wossman High
Name of School
Monroe La
Location Graduated?
Yes No
Name of School Graduated / completed program?
Yes No
Major Still attending?
Yes No
Name of School Graduated / completed program?
Yes No
Major Still attending?
Yes No
List any special training or skills.
EMPLOYMENT ELIGIBILITY
Are you eligible to work in the US?
Yes No
Are you at least 18 years or older?
Yes No
Are you able to communicate, read, and write in English? Yes No
CRIMINAL HISTORY
Have you ever been convicted of any felony or misdemeanor offenses? Note: Answering 'yes' does NOT automatically exclude you from employment with Leading Home Care. Please answer honestly.
If yes, please describe the date and nature of the conviction. Please select one:
Yes No
Please explain.
ATTRIBUTES
AVAILABILITY
Select "Yes" if you have open availability for all hours. Select "No" to list specific dates/times that you are available to work. HOW DID YOU HEAR ABOUT US?
If you were referred by an employee of Leading Home Care, please list their name: Certification & Release
Do you have an active CNA certification?
Do you have experience working with persons diagnosed with developmental disabilities?
Do you have experience working with persons who are elderly? Based on the Job Description are you able to perform the essential functions of the job, with or without accommodation?
Do you have any work restrictions that LHCL should know about? If yes, please explain.
Yes No
Yes No
Yes No
Yes No
Yes No
If yes, please explain.
Are you able to bear weight up to 50lbs and assist with client transfers? Do you smoke cigarettes?
Are you comfortable working in homes where cigarettes are smoked? Are you afraid of and/or allergic to pets/animals? If yes, please describe.
(example: allergic to cats, afraid of dogs)
Do you have access to a personal vehicle that you are able to drive for work?
(Only select YES if vehicle is insured & inspected.) Yes No
Yes No
Yes No
Yes No
If yes, please describe.
Yes No
Open availability?
Yes No
Work Schedule Comments
How soon are you available to begin working?
Select date
Nov 10 2024
What areas are you able to work or travel to?
Monroe/West Monroe
List area of availability
I heard about Leading Home Care from:
Now Hiring Sign
Online Job Board (Indeed, etc.)
Job Fair
Social Media (Facebook, etc.)
Online Search (Google, etc.)
Referred by Employee
Referred by Client
Other (please describe)
Comments (optional)
Have you ever worked for Leading Home Care?
Yes No
Jonathan Grant
Employee Name
I certify the above stated and indicated are true and complete to the best of my knowledge, and no misrepresentation of myself has been made. I understand that any false information, omissions, or misrepresentation of facts will result in rejection from this application and/or discharge at any time during employment period. I authorize Leading Home Care to verify any and all information contained within this application, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said parties from any liability for any damage whatsoever for issuing this information. I also 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. Agree?
Yes No
Today's Date
Nov 9 2024
Signature
Signed Nov 9 2024 9:26 AM
Contact this candidate