Home Care Jobs | Connecticut In-Home Assistance

Name:

Email address:

Home phone number:

Present address

City

State

Zip Code

Languages Spoken

Emergency contact name

Emergency contact number

Positions Interested In

Companion

Homemaker

Personal Needs Assistant

Heavy Cleaning

Do you have a car available for daily use?

Do you have a vehicle that can transport items to the dump?

Do you hold a current drivers license?

Would you be willing to use your car for client errands?

Would you be willing to use your car for client transportation?

Do you have any physical impairments that would interfere with your ability to perform the activities required of your position?

If yes, please explain:

Have you ever been convicted of a crime of have criminal charges pending, excluding misdemeanors?

If yes, please explain:

PLEASE NOTE:

Work schedule is based on client needs. Full-time work is not guaranteed. Most work schedules begin as part-time.

Please fill in the hours you are available to work each day:

MON

TUE

WED

THU

FRI

SAT

SUN

Are you interested in 12 or 24 hour shifts?

Do you have any allergies to pets, cigarette smoke, other?

If yes, please explain:

What is the highest grade completed?

School name & location

Additional Training (check all that apply):

Registered Nurse

Licensed Practical Nurse

Certified Nurse's Aide

Home Health Aide

State of Licensure:

Date of Licensure/Certification:

Name of employer - Dates employed from/to - Position

Personal reference name - Relationship - Phone number

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