Polish Helping Hands, 15 New Britain Ave, Unionville, CT 06085, ph: 860-404-0499; fax: 860-404-0465
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Employment Opportunities

Employment Application:
Date: mm/dd/yyyy
Last:    First:
Cleaning   Elderly Care   Baby-Sitting
Live In   Hourly Salary Desired:
Morning   Afternoon  Evening  Night

Last Name:

Date of Birth:
State:    Zip:
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:

Name: Phone:
How Long Were You There?
Reason for Leaving?
How Many Children?
Ages of Children:
Notes for PHH:

You Can Trust Polish Helping Hands,