Form Test Job Opportunities Name * (First, Middle, Last) Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Date of Application Email Address * Home Phone * Cell Phone * Are you 18 years of age or older? * Yes No Do you have a valid Driver's License? * Yes No Are you legally authorized to work in this country? * Yes No Do you have any physical limitations? * Yes No If yes, what accommodations or limits on duties do you require? Have you ever been convicted of a felony or misdemeanor? * Yes No If yes, please describe: How did you hear about Living Care Home Services? Date available to start work Position Desired: * Live-In Hourly Please complete availability below: Sunday Start Time 12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pm Sunday End Time 12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pm Monday Start Time 12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pm Monday End Time 12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pm Tuesday Start Time 12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pm Tuesday End Time 12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pm Wednesday Start Time 12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pm Wednesday End Time 12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pm Thursday Start Time 12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pm Thursday End Time 12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pm Friday Start Time 12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pm Friday End Time 12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pm Saturday Start Time 12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pm Saturday End Time 12:00 am1:00 am2:00 am3:00 am4:00 am5:00 am6:00 am7:00 am8:00 am9:00 am10:00 am11:00 am12:00 pm1:00 pm2:00 pm3:00 pm4:00 pm5:00 pm6:00 pm7:00 pm8:00 pm9:00 pm10:00 pm11:00 pm EDUCATION High School (Name & Location) College/Trade School (Name & Location) Subjects Studied Are you a Certified Nursing Assistant (CNA)? Yes No Are you a Certified Home Health Aide (HHA)? Yes No EXPERIENCE Please list your three most recent employers starting with the most recent. This should include the name, address, phone number, dates employed, salary and reason for leaving. Please check all you have experience with: Bathing Dressing Toileting Incontinence Hair Care Skin Care Mouth Care Medication Assist Feeding Assist Nutrition Transferring Hoyer Lift Dementia Alzheimers Hospice By inserting your name below, you certify that all the information furnished on this application and during the application process is true, complete and correct to the best of your knowledge. You understand that any misrepresentation or omission of facts called for may result in refusal to be hired, placed on the Living Care Home Services Registry, or if placed on the Living Care Home Services Registry, may result in dismissal at any time regardless of when the false answer or omissions are discovered. Additionally, you agree to comply with the Pennsylvania state requirements regarding criminal history background checks for health care employment. * Date reCAPTCHA If you are human, leave this field blank. Submit Δ
