Visiting Angels Employment Application
Carefully and accurately fill out all fields. When ready, click "Submit" below.
First Name
ex. Nancy
Last Name
ex. Smith
Email Address
ex. name@domain.com
Primary Phone
555-555-5555
Alt. Phone
555-555-5555
Address
suite/Apt# on 2nd line
City, State, Zip
ex. Walla Walla, WA 99216
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