Employment Opportunities

Employment Application:
Date: mm/dd/yyyy
Name: Last:    First:
Cleaning   Elderly Care   Baby-Sitting
Live In   Hourly	Salary Desired:
Hours Morning   Afternoon  Evening  Night
Last Name:	Date of Birth:
Telephone:
Address:
City:	State:    Zip:
Email:
Social Security Number:
Are You A Citizen or Resident: Citizen Resident
Do You Have a Car? Yes No
Do You Have a Drivers License? Yes No
Do You Speak English? Yes No Good Little
Have You Been Convicted of a Crime in the U.S.? Yes No
If Yes, Please Provide Full Details:
Marital Status: Married   Single
Additional Personal Information
How Long Have You Been in the U.S.?
Do You Have a College Education? Yes   No
What Are Your Hobbies?
Do You Have Special Training?
Do You Smoke Cigarettes? Yes   No
Do You Drink Alcohol? Yes   No
Medical Condition?
Are You Currently Working? Yes   No
References with Elderly, Children, and Cleaning Only
Name:	Phone:
How Long Were You There?
Reason for Leaving?
Medical Condition Alzheimer's  Arthritis  Cancer  Incontinence Depression  Lung Disease  Diabetes  Heart Disease   Parkinson's  Stroke  Surgery
Notes from PHH:
Baby-Sitting
Name:	Phone:
How Long Were You There?
Reason for Leaving?
How Many Children?
Ages of Children:
Notes for PHH: