Visiting Angels Employment Application

Carefully and accurately fill out all fields. When ready, click "Submit" below.



1. How many hours can you work weekly?
2. Do you have a valid license?
Yes No
3. Do you have a car
Yes No
4. Drivers license #
5. Are you available to work nights?
Yes No
6. Are you legally authorized to work in this country?
Yes No
7. would you consider live-in shifts?
Yes No
8. Are you available to work weekends?
Yes No
9. Times you are not available to work
10. Certifications and professional Licenses
11. Please indicate whether you have assisted with or performed the following tasks . Companionship?
Yes No
12. Meal Preparation
Yes No
13. Light Housekeeping?
Yes No
14. Bathing/ Showering?
Yes No
15. Dressing/ Grooming?
Yes No
16. Transferring?
Yes No
17. Incontinence Care?
Yes No
18. Dementia/ Alzheimers?
Yes No
19. Hoyer Lift?
Yes No
20. Additional Skills
21. Employment History Most recent
22. From
23. To
24. Duties?
25. Supervisor
26. Phone
27. May we contact
Yes No
28. Company
29. From- To
30. Duties
31. Supervisor
32. Phone
33. May we contact?
Yes No
34. Have you been convicted of a felony?
Yes No
35. If yes , explain the nature and dates of the convictions
36. Have you been convicted of a crime?
37. What do you like most about working with the elderly, disabled , or convalescing client?
38. What do you find most challenging in this type of work?
39. Position Applying for?
40. Do you have a valid TB test?
Yes No