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Employment Application

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PERSONAL INFORMATION

Position Desired
Your Name
Your Email Address
Address
When is the best time for us to reach you via telephone?
Social Security #
Marital Status
 
Height
Weight
Gender
 
Maiden Name
Have you gone by any other names? Please list.
Do you have children?
Current ages of children?
 
Have you ever been convicted of a felony, misdemeanor, or municipal violation other than traffic?(Required)
If yes please explain:
Have you ever been involved in a civil lawsuit?(Required)
If yes please explain:
Do you have any pending criminal charges or civil lawsuits?(Required)
If yes please explain:
Have you ever been bonded?(Required)
If yes please explain:
If asked, after receiving a conditional offer of employment, would you submit to a routine physical exam?(Required)
If asked, would you take a drug test?(Required)
Do you drink alcohol?(Required)
Do you smoke tobacco?

BACKGROUND INFORMATION

Please provide additional information reflecting past 10 years
Previous addresses - click "+" for additional rows
Have you been fingerprinted? If yes, please provide date and reason:
Are you legally allowed to work in the US?

EMERGENCY CONTACT

Please provide an emergency contact
Name
Address

TRANSPORTATION

Do you drive?
Do you have a valid drivers license?
Drivers license #
Do you have any tickets or moving violations?
If yes please provide date and year and explain:
Will you drive your own vehicle on the job?
Year, make and model of vehicle:
License plate #
State of registration
State insured in:

MEDICAL INFORMATION

Do you have medical insurance?
Insurance provider:
Are your immunizations up to date?
Date of last physical?
Have you had a chest x-ray within 5 years?
Have you ever tested positive for HIV?
Have you ever tested positive for Tuberculosis?

EMPLOYMENT INFORMATION

Are you able to work legally in the United States?(Required)
Are you a?(Required)
When are you able to begin work?
Will you live-in?
What type of employment are you seeking?
Hours You Are Available for Work
Please tell us what hours you are available for work each day of the week.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
 
What areas are you willing to work?
Are you willing to work around pets?
Are you willing to work around children?
Are you free to travel?
If you are free to travel, how often?
What is your desired salary (please specify - monthly, yearly, or hourly)?

CHARACTER REFERENCES

Please provide 3 character references that are not family members
Character Reference #1 - Name
Address
Character Reference #2 - Name
Address
Character Reference #3 - Name
Address

EDUCATION AND TRAINING

Please tell us a little bit about your prior education and training
Did you graduate high school?
Do you have a college degree?
Do you speak a foreign language?

Are you working with other placement agencies?

EXPERIENCE

Please check if you are experienced in the following areas or are willing to gain experience.
Change Diapers
Infant Car
Child Care
Menu Planning
Shopping
Simple Cooking
Menu Planning
Special Diet Cooking
Formal Serving
Laundry
Dishwashing
Hand Laundry
Ironing
Housekeeping
Wall Cleaning
Clean Refrigerator
Clean Oven
Elderly Care
Care of Bedridden
Wheelchair Safety
Lifting of Patients
Landscaping
Yard Work
Pool Maintenance
Plumbing Repair
Electrical Repair
Carpentry

PREVIOUS EMPLOYMENT

Your Previous Employers
Please list your previous employers, the dates you worked and the position you held
Employer
Dates
Position
Phone
 

For More Information

(602) 996-0882

info@camelviewdomestic.com

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