Employment Application

* All prospective caregivers will take a short written test prior to their interview.

Personal Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Certifications
- CNA
- NAR
- LPN
- RN
Other Credentials
- Nurse Delegation
- Nurse Delegation with Focus on Diabetes
- Mental Health
- Dementia
- CPR/First Aid
- Orientation and Safety
- Washington State Food Worker Card
- Other
Other Credentials
Please describe yourself*
Job Questions
Do you have a reliable way to get to work on time?*
- Yes
- No
Have you ever been convicted of a felony?*
- Yes
- No
Are you over 18 years old?*
- Yes
- No
Do you have experience using Microsoft Office (Word, Excel) or similar?*
- Yes
- No
Can you speak, read and write the English language proficiently?*
- Yes
- No
Are you legally authorized to work in the United States?*
- Yes
- No
Can you lift up to 50 lbs. without assistance?*
- Yes
- No
What do you think would be a good reason to be absent from work?*
What would be a reason for you to quit without notice?*
How do you handle people who are hard to get along with?*
What is your level of education?*
What was your last job?*
What were your duties at your last job?*
Please list two references with contact information.
Reference 1*
Reference 2*
Job Expectations/Availability*
Are there any medical condition that which may limit your ability to perform the job applied for?*
- Yes
- No
Please describe job hindering medical conditions.*
File Uploads
Please use this to upload all certificates along with your CPR and First Aid card.
Drop files here or

Max. file size: 50 MB.
Please check the box below
Comments
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* All prospective caregivers will take a short written test prior to their interview.

Employment Application

Personal Information

Job Questions

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