* Required Information
PERSONAL INFORMATION

(Last)(First)(Middle)
I would like a job as a full time Live-In Companion : YesNo
What days are you available to work?
I would like a job as a full time Live-Out Companion : YesNo
What days and hours are you available to work?
Have you ever been registered with LHC before? YesNo
If yes, please give dates
Reason for leaving :
How did you hear of us?
Do you have a valid driver’s license? YesNo
If Yes, from what State
License Number :
EDUCATION
High School Name : *
State or Country : *
Graduate : * Yes  No
College Name : *
State or Country : *
Graduate : * Yes  No
Type of Degree : *
PERSONAL REFERENCES
Give the names of three persons (you have not worked with, and are not related to you).
Name * Telephone Number * Occupation *
EMPLOYMENT HISTORY
List all present and past employment beginning with your most recent. FOR ALL PERIODS OF UNEMPLOYMENT IN EXCESS OF THREE MONTHS, PLEASE GIVE AN EXPLANATION.
From : *  To : * 
Job Title : *
Name of Employer : *
Address of Employer : *
Reason for leaving : *
Type of work you performed : *
From :   To :  
Job Title :
Name of Employer :
Address of Employer :
Reason for leaving :
Type of work you performed :
From :   To :  
Job Title :
Name of Employer :
Address of Employer :
Reason for leaving :
Type of work you performed :
I HEREBY AUTHORIZE LOUDOUN HOME CARE TO REQUEST AND RECEIVE FROM ALL PRIOR EMPLOYERS WITHIN ONE YEAR OF THE DATE OF THIS APPLICATION, ANY AND ALL PERTINENT INFORMATION CONCERNING MY PRIOR EMPLOYMENT AND ITS TERMINATION, INCLUDING THE REASONS FOR SUCH TERMINATIONS. I hereby state that all of the foregoing information I have supplied in this application is a true and complete statement of the facts. False statements contained in this application are immediate cause for dismissal from registrant caregiver status. I further give my permission for this agency to verify all schooling and references.

* Security Code