Employment Department

What languages do you speak?*
Please alert us to any limitations you might have in order to avoid injury while on the job (i.e., back injury)
Can you stoop, bend, and lift up to 25lbs?*
- Yes
- No
Do you have any known allergies? If yes, please list
One of the services our agency provides is pet care. Do you have any objections caring for a cat, dog, bird, or other pet? Caring for them may include feeding them, walking them, cleaning up after them, etc.*
- Yes
- No
If yes please explain
Do you have any contagious diseases or health issues?*
- Yes
- No
If yes please explain
Do you smoke?*
- Yes
- No
Do you cook? If so, please rate your cooking ability on a 0 – 10 scale*

Please enter a value between 0 and 10.

List your past Caregiver experience:
List all present and past employment beginning with your most recent. For all periods of unemployment in excess of three months, please give an explanation.
Employment Details

Be sure to list, date-range, job title, contact information, reason for leaving, and type of work you performed.
Employer
Employer Details

Be sure to list, date-range, job title, contact information, reason for leaving, and type of work you performed.
Employer
Employer Details

Be sure to list, date-range, job title, contact information, reason for leaving, and type of work you performed.

Permission for Background Check*
- By checking this box, I give Premier Senior Home Care permission to do a criminal background on me.
For example of background check form which is to be filled out in office Click Here
I HEREBY AUTHORIZE Premier Senior Home Care TO REQUEST AND RECEIVE FROM ALL PRIOR EMPLOYERS WITHIN ONE YEAR OF THE DATE OF THIS APPLICATION ANY AND ALL PERTINENT INFORMATION CONCERNING MY PRIOR EMPLOYMENT AND ITS TERMINATION, INCLUDING THE REASONS FOR SUCH TERMINATIONS. I hereby state that all of the foregoing information I have supplied in this application is a true and complete statement of the facts. False statements contained in this application are immediate cause for dismissal from registrant caregiver status. I further give my permission for this agency to verify all schooling and references.*

First
Last
Date*

By electronically signing this document you agree to the legal terms and continues previously stated.

1st Personal Reference: