* Required Information
PERSONAL INFORMATION
Date :
*
Name :
*
(Last)
(First)
(Middle)
Address :
*
Home Phone :
*
Cell Phone:
Alt. Phone :
E-Mail :
*
Social Security # :
I would like a job as a full time Live-In Companion :
Yes
No
What days are you available to work?
I would like a job as a full time Live-Out Companion :
Yes
No
What days and hours are you available to work?
Have you ever been registered with LHC before?
Yes
No
If yes, please give dates
Reason for leaving :
How did you hear of us?
Do you have a valid driver’s license?
Yes
No
If Yes, from what 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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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.
Submit