Stay at Home Personal Care Application Form

Application Form

Please Note: You must be 18 years or older to apply for a job with Stay at Home Personal Care. All contact through the application process is done primarily by telephone. Please check your messages regularly. Due to the high volume of applications we receive, we can only consider applications that are filled out completely. Failure to answer all questions may result in your application being rejected. We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including gender, race, color, age, sex, religion, disability, medical condition, national origin, or marital status.

Office Location

Select Office Location

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - General Information

Are you currently employed? (required)

Yes No

Expected Pay Rate: (required)

What position are you applying for? (required)

Date Available? (required)

Job Type? (required)

Can you provide documentation of a driver's license and auto insurance? (required)

Yes No

Driver License Expiration Date:

Auto Insurance Expiration Date:

Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in this state or any other? (required)

Yes No

If yes, please explain.

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Section 2 - Employment Eligibility

Are you a U.S. citizen? (required)

Yes No

If you are not a U.S. citizen, please indicate VISA type and number.

Are you authorized to work in the U.S.? (required)

Section 3 - Education

Name of High School: (required)

Location of High School: (required)

Did you graduate? (required)

Yes No

Years Attended (From/To): (required)

Additional Education (vocational, undergraduate, etc.)

Yes No

If yes, please list the name of the school and years attended (From/To)

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Section 4 - Other Training: Certifications/Licenses

Certifications/Licenses:

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Section 5 - Current Employer

Current Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Describe Your Responsibilities:

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Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

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May we contact?

Yes No

Section 6 - Previous Employer

Last Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Describe Your Responsibilities:

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Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

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May we contact?

Yes No

Section 7 - Previous Employer

Employer Name:

Address:

City:

State:

Zip Code:

Phone Number:

Start Date:

End Date:

Hours Worked:

Position/Title:

Describe Your Responsibilities:

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Supervisor's Name/Title:

Reason for Leaving:

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May We Contact?

Yes No

Section 8 - Professional (Work) Reference 1

How many years have you known this person? (required)

Is this person related to you? (required)

Yes No

Name: (required)

Company: (required)

Phone: (required)

Section 9 - Professional (Work) Reference 2

How many years have you known this person? (required)

Is this person related to you? (required)

Yes No

Name: (required)

Company: (required)

Phone: (required)

Section 10 - Personal Reference

How many years have you known this person? (required)

Is this person related to you? (required)

Yes No

Name: (required)

Company: (required)

Phone: (required)

Section 12 - Getting to Know You

Summarize your special skills and qualifications. (required)

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What are you passionate about? (required)

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Describe a bad customer service experience you've recently had. (required)

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Describe a good customer service experience you've recently had. (required)

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I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, educational, financial, criminal and other related matters as may be necessary for an employment decision. I hereby release employers, schools, or individuals from all liability when responding to inquiries in connection with my application. In the event I am employed, I understand that false or misleading information given in my application or interview(s) may result in discharge.

Signature