CAREGIVER APPLICATION Name First Last Email Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneMobile PhoneSocial Security NumberBirth Date MM slash DD slash YYYY Drivers LicenseDrivers License Yes No State Add RemoveDo you own your own car? Yes No Are you willing to transport clients in your own vehicle? Yes No EducationCollege/University1 College/University Location1 Major1 Graduation End Date 1 MM slash DD slash YYYY Graduate Yes No College/University2 College/University Location2 Major2 Graduation End Date 2 MM slash DD slash YYYY Graduate Yes No Specialized TrainingPrevious experience/qualificationsAdditional certificationsOther languages spokenGeneral AvailabilityAre you available all hours? Yes No Current availabilityAre you willing to work overnight shifts? Yes No Skills and PreferencesPlease check any of the following you are willing to work with: Companionship Galt Belt Incontinence Driving Transfer Assit Smoking Alzheimer's/Dementia Males Females Dogs Cats Select AllPlease check all you have experience with: Galt Belt Incontinence Transfer Assist Alzheimer's/Dementia Criminal HistoryHave you ever been convicted of any felony or misdemeanor offenses? Yes No Criminal offensesAdditional QuestionsAdditional QuestionsCERTIFICATION AND RELEASECertification and Release(Required)I certify the above stated and indicated are true in fact and no misrepresentation of myself has been made. I understand that any false information, omissions or misrepresentations of facts will result in rejection from this application and/or discharge at any time during employment period. I authorize THE WRIGHT CHOICE, LLC to verify any and all information contained within this application, 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 and that I am willing to submit to drug testing at any time to detect the use of illegal drugs prior to or during employment. Agree?RESTRICTIVE COVENANTConsent(Required)I agree not to do business directly with any individual or business entity that THE WRIGHT CHOICE, LLC has introduced to me or by entering into employment with such individuals or busiensses. I agree to the Restrictive Covenant.EmailThis field is for validation purposes and should be left unchanged.
