Date: 9/03/2010

Application Form

Blessings For Seniors
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.

Office Location
Select Office Location:

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 - Applicant Questions
Number Question Effective Date Expiration Date
0 Application Date (required)  
  N/A N/A
1 What Postion are you applying for? (required)  
  N/A N/A
2 Do You have an Insured and Reliable Vehicle? (required)  
  N/A N/A
3 Do You Know Someone Who Works for us? (required)  
  N/A N/A
4 How did You Hear about Blessings! (required)  
 
5 Year, Make and Model of Vehicle (required)  
 
6 Do You have an Email Address and Internet Access at Home (required)  
  N/A N/A
7 Do You have a Cell Phone (required)  
  N/A N/A
8 Have you ever been Convicted of a Felony (required)  
  N/A N/A
9 Number of Hours Available for Work? (required)  
  N/A N/A
10 Days and Times You are Available to Work? (required)  
 
11 Days and Times You are NOT Available to Work? (required)  
 
12 Where did you attend High School? College?  
  N/A N/A
13 Degrees or Certificates  
  N/A N/A
14 Discuss any Training or Experience Working with the Elderly (required)  
 
15 Why Do You Want to Work with the Elderly (required)  
 
16 What Do You Like Least about Working with the Elderly?  
 

Section 2 - Skills:Experience with the Following
Number Question Effective Date Expiration Date
1 Companionship?  
  N/A N/A
2 PersonalCare/Bathing/Dressing?  
  N/A N/A
3 Incontinence or Toileting Assistance?  
  N/A N/A
4 Light Houskeeping?  
  N/A N/A
5 Transfer Assist?  
  N/A N/A
6 Cooking?  
  N/A N/A
7 Medication Reminders?  
  N/A N/A
8 Transportation?  
  N/A N/A
9 Other Skills Relevant to Working with the Elderly?  
 

Section 3 - Employment History
Number Question Effective Date Expiration Date
1 May we Contact Your Current Employer?  
  N/A N/A
2 Minimum of 3 Past/Present business references to include: Company Name, Job Title and duties, Dates Employed, Supervisor Name, CONTACT PHONE NUMBER (required)  
 

Section 4 - Other References
Number Question Effective Date Expiration Date
1 Minimum of 3 Personal References with Contact Phone Numbers ( No Relatives) (required)  
 



CERTIFICATION AND RELEASE: I certify that I have read and understand the application note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the employer and/or its agents, including consumer reporting bureaus, to verify any information including, 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 persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.  I understand that, if hired, my employment is “at will”, and may be terminated by either the employer or me at any time.  No one affiliated with the employer has made any statement or promise that is contradictory or inconsistent with “at will” employment, nor has anyone made any statement or promise that I will be hired.