Pinellas/Pasco 727-787-8677 and Hillsborough 813-884-6100
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Pinellas/Pasco 727-787-8677 and Hillsborough 813-884-6100
Home
About
In-home Care
Case Management
Testimonials
Blog
Become a Caregiver
Contact
Apply
Recruiting Form
Thank you for your interest in contracting with our agency. We look forward to reviewing your experience and skills. Please submit the following information in order to be considered for a contract caregiver position.
1
Applicant Information
2
Education, Certifications & Credentials
3
Work History
Name
*
First
Middle
Last
Address
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Phone
*
Email
This is contract work, not employment. Are you willing to contract with our agency for work?
*
Yes
No
Number of hours wanted weekly and days of the week preferred
Please select your skills and preferences.
Dementia Experience
*
Yes
No
Hospice Experience
*
Yes
No
Incontinence Experience
*
Yes
No
OK with Client Smoking
*
Yes
No
Gait Belt Experience
*
Yes
No
Hoyer Lift Experience
*
Yes
No
OK with Cats
*
Yes
No
OK with Dogs
*
Yes
No
Education & Training
Select Your Highest Level of Education
High School
Some College
College Degree
Name of School
Degree Received (if applicable)
Certifications and Credentials
Driver's License
*
Yes
No
Car Insurance in Your Name
*
Yes
No
Social Security Card/Resident Alien Card
*
Social Security Card
Resident Alien Card
Neither
CNA License/HHA Certificate
*
Yes
No
CPR Certification
*
Yes
No
HIV/Aids Training
*
Yes
No
Level 2 Background
*
Yes
No
Medication Assistance Training – 2 Credit Hours
*
Yes
No
Alzheimer’s/Communicating with the Cognitively Impaired – 2 Credit Hours
*
Yes
No
Domestic Violence Training
*
Yes
No
Medical Errors Training
*
Yes
No
Medical Record Documentation
*
Yes
No
Residents Rights
*
Yes
No
Are any of the above expired? If so, which ones?
Additional Certifications or Credentials
Colostomy Skills
*
None
Empty
Change
Catheter Skills
*
None
Empty
Switch Drainage Bags
Hoyer Lift Experience/Training
Yes
No
Will you drive clients to errands, doctor appts, grocery, etc.?
Yes
No
Do you cook, clean, and do laundry?
*
Yes
No
What hours do you want to work? Length of shift?
How far are you willing to travel? OR List the cities you will drive to.
Work History
Please provide your most recent positions.
Employer
*
Supervisor
*
Phone
*
Address
*
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Date Employed
*
MM
DD
YYYY
To
Leave blank if you are still in this position.
MM
DD
YYYY
Reason for Leaving
*
Employer
Supervisor
Phone
Address
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Date Employed
MM
DD
YYYY
To
MM
DD
YYYY
Reason for Leaving
Employer
Supervisor
Phone
Address
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Date Employed
MM
DD
YYYY
To
MM
DD
YYYY
Reason for Leaving
Additional Information
Professional References
Please provide the name and phone number of at least two professional references.
Professional Reference 1
Professional Reference 2
Professional Reference 3
Why did you become a CNA/HHA?
APPLICATION AUTHORIZATION AND CONSENT FOR RELEASE OF INFORMATION
*
This release and authorization acknowledges that this company may now or at any time while you are under contract, conduct a verification of your education, previous employment/work history, contact personal references, require that you provide a urine specimen or blood specimen to be tested for the presence of drugs or alcohol and receive any criminal history record information pertaining to you that may be in the files of any federal, state, county, or local criminal justice agency and/or other information as deemed necessary to fulfill job requirements. The results of this verification process will be used to determine eligibility under this company's placement policies. I authorize Care Placement Home Health Agency, Inc. and any of its agents/designated company personnel, to disclose orally and in writing the results of the verification process. The information obtained will not be provided to any other parties other than to the designated authorized representatives of this company. All results will be kept CONFIDENTIAL. I, the undersigned applicant, do hereby certify that the information provided by me for the purpose of placement is true and complete to the best of my knowledge. I understand that if I am placed, any false statement will be considered as cause for possible dismissal.
I agree
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