Cheerway Care Application Form
Application Form
We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.
Personal Information
First Name
*
Last Name
*
Home Phone
*
Work Phone
Mobile Phone
Email
*
Address 1
*
Address 2
City
*
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisana
Maine
Maryland
Massachusetts
Michigan
Military Personnel - America
Military Personnel - Europe
Military Personnel - Pacific
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Minor Outlying Islands
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Zip
*
Driver's License Number
--
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
GU
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
AA
AE
AP
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UM
UT
VT
VI
VA
WA
WV
WI
WY
AB
BC
MB
NB
NL
NT
NS
NU
ON
PE
QC
SK
YT
Section 1 -
Basic Information
Are you able to provide original documentation which establishes your identity and authorization to work in the United States?
(required)
Yes
No
Please enter the last 4 digits of your Social Security Number.
(Numeric Answer Only)
Do you have a valid driver's license?
(required)
Yes
No
Are you willing/able to act as a vehicle driver?
(required)
Yes
No
Section 2 -
Background Checks
Are you willing to submit to a drug test?
(required)
Yes
No
Section 3 -
Education History
Do you have a High School Diploma or GED?
(required)
Yes
No
Type of Degree (i.e Bachelors, Associate, Certificate, etc)
College or Institution (Name and Address)
Date/Year Completed
Section 4 -
Availability
Which days are you available to work?
(required)
-- Select an Option --
Weekdays only
Weekends only
Weekdays and Weekends
Which part of the day are you available to work?
(required)
-- Select an Option --
AM
PM
Both AM and PM
Are you available for live-in cases?
(required)
Yes
No
Where are you willing to work?
-- Select an Option --
Maryland
Northern Virginia
Both
Section 5 -
Credentials (Please complete entirely.)
Are you a Certified Home Health Aide?
(required)
Yes
No
Are you a Certified Nursing Assistant?
(required)
Yes
No
Effective Date
*
Are you a Geriatric Nurse Assistant?
(required)
Yes
No
Effective Date
*
Are you a Certified Medication Technician?
(required)
Yes
No
Effective Date
*
Are you a Licensed Practical Nurse?
(required)
Yes
No
Effective Date
*
Are you CPR certified?
(required)
Yes
No
Effective Date
*
Are you AED certified?
(required)
Yes
No
Effective Date
*
Are you First Aid certified?
(required)
Yes
No
Effective Date
*
Section 6 -
Employment History
Please copy and paste your resume below.
(required)
Show Plain Text
Current Employer or Most Recent (Name/Address/Phone/Pay$$)
(required)
May we contact your current employer?
(required)
Yes
No
Previous Employer (Name/Address/Phone/Pay$$)
(required)
Previous Employer (Name/Address/Phone/Pay$$)
Previous Employer (Name/Address/Phone/Pay$$)
Section 7 -
References (No Relatives Please)
Professional Reference (Company, Title, Phone/Email)
(required)
Professional Reference (Company, Title, Phone/Email)
(required)
Professional Reference (Company, Title, Phone/Email)
(required)
Professional Reference (Company, Title, Phone/Email)
(required)
How did you find out about Cheerway Care? __Friend/Family/Co-worker (please write name in the box) __Advertisement __Other: ________
I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.
Signature
Submit Application
