Happier at Home Spring Application Form

Application Form

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, medical condition, national origin, or marital status.

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

Date Available to begin work? (required)

Position for which you are applying: (required)

Number of hours you would like to work per week: (required)

Days of week AND times each day that you are available to work: (required)

How did you learn of our job opening? (required)

Do you have a valid driver's license? (Please note that this is required for all caregiver positions) (required)

Yes No

Do you have your own reliable car with insurance? (Please note that this is required for all caregiver positions) (required)

Yes No

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.

I understand that all employees of Happier at Home will be paid by direct deposit or debit card. Should I be offered and accept employment, I consent to receiving my pay through direct deposit to the bank of my choosing, or through a debit card. (required)

Yes No

I understand that I must be available to work one weekend per month, though I may choose to work more than one weekend. (required)

Yes No

I understand that I may be required to provide care to clients regardless of race, color, religion, sex, or national origin. (required)

Yes No

Section 2 - Employment Verification

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

Section 3 - Education

High School Name with City/State: (required)

Did you graduate? (required)

Yes No

Additional Education (vocational, college, etc.)

Yes No

If yes, Name of the school and area of study:

Section 4 - Skills/Languages Spoken/Certifications/Licenses:

Certifications/Licenses:

Please list other languages you speak in addition to English:

Which choice best describes your kitchen skills: (required)

Section 5 - Caregiving Experience

What motivates you to be a caregiver? (required)

Describe your caregiving experience with seniors and/or the disabled: (required)

Do you have experience working with clients with dementia, Alzheimers, or similar cognitive disability? (required)

Yes No

Section 6 - Current Employment

Current Employer: (required)

City/State: (required)

Start Date:

End Date:

Position/Title:

Describe Your Responsibilities:

Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

May we contact?

Yes No

Section 7 - Prior Employment

Last Employer:

City/State:

Start Date:

End Date:

Position/Title:

Describe Your Responsibilities:

Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

May we contact?

Yes No

Section 8 - Professional Reference 1

Name: (required)

Company: (required)

Phone: (required)

Section 9 - Professional Reference 2

Name: (required)

Company: (required)

Phone: (required)

Section 10 - Personal Reference 1 - NO Family Members

Name: (required)

Years Known: (required)

Phone Number: (required)

Relationship: (required)

Section 11 - Personal Reference 2 - NO Family Members

Name: (required)

Years Known: (required)

Phone Number: (required)

Relationship: (required)

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

Signature