Caregiver Application Caregiver Employment Application Love 2 Live is an equal opportunity employer. Love 2 Live makes employment decisions without regard to sex, race, color, religion, national origin, ancestry, age, disability, medical condition, gender identity, sexual orientation, marital status, veteran status, or any other legally protected characteristic. Step 1 of 6 16% Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Mobile PhoneEmail* Min. Salary Requirement* How did you hear about us? Have you ever been convicted of a crime?* Yes No Exclude convictions for marijuana-related offenses for personal use more than two years old; convictions that have been sealed, expunged or legally eradicated, and misdemeanor convictions for which probation was completed and the case was dismissedExplain:*Please briefly describe the nature of the crime(s), the date and place of conviction and the legal disposition of the case. This company will not deny employment to any applicant solely because the person has been convicted of a crime. The company however, may consider the nature, date and circumstances of the offense as well as whether the offense is relevant to the duties of the position applied for.Home Care Aide Licensing RequirementHave you completed your Home Care Aide registration through the Home Care Services Bureau?* Yes No If, NO, please contact Love 2 Live office to discuss the registration process. You can also visit http://www.ccld.ca.gov/pg3654.htm for more information or to begin the registration process.Please provide your 10-digit HCA number:* Emergency ContactName First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneRelationship AvailabilityTell us about your availability. Be very specific. What days, hours? Any scheduling challenges we should know about?Monday: Tuesday: Wednesday: Thursday: Friday: Saturday: Sunday: What days or hours can you NEVER work?How many hours do you need to work per week?* Would you ever consider doing a 24 hour shift for a couple of days?* Yes No If we had an emergency (someone needing extra care, someone not showing up for work), could we call you at the last minute?* Yes No Preferred Work AreaHow far are you willing to drive to for a shift? Again, be very specific, tell us how many miles, what parts of town, or how much driving time. Remember that the more flexible you are with areas you will work, the better schedule we will be able to give you. We have clients all over the city!TransportationMany caregiver positions require the caregiver to transport a client.Do you have dependable transportation?* Yes No Are you able to safely transport clients in your vehicle?* Yes No (Shopping, Doctor Appts, Etc.) EducationHigh School City/State Major College City/State Major Other City/State Major Certificates/Training Employment HistoryPlease provide your last 3 employment positions held below and attach a resume including at least five years and tell us about your work history.Do you have experience as a Caregiver?* Yes No How much?*Please explain your experience and how long you've been doing it.Previous Employment #1Company* From MM slash DD slash YYYY To MM slash DD slash YYYY Job Title* Reason Left* DutiesSupervisor Phone*May we contact this employer?* Yes No Starting Salary* Ending Salary* Previous Employement #2Company* From MM slash DD slash YYYY To MM slash DD slash YYYY Job Title* Reason Left* DutiesSupervisor Phone*May we contact this employer?* Yes No Starting Salary* Ending Salary* Previous Employment #3Company* From MM slash DD slash YYYY To MM slash DD slash YYYY Job Title* Reason Left* DutiesSupervisor Phone*May we contact this employer?* Yes No ResumeYour resume should include at least five years of employment history and describe your work history. We prefer PDF documents, however, DOC and DOCX are accepted as well.Accepted file types: pdf, doc, docx, Max. file size: 512 MB. Professional ReferencesNo personal references please.Name First Last Relation Years Known PhoneName First Last Relation Years Known PhoneName First Last Relation Years Known Phone Certification and ReleaseI certify that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for Love 2 Live Care Services to hire me. If I am hired, I understand that either Love 2 Live Care Services or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of Love 2 Live Care Services has the authority to make any assurance to the contrary.Digital Signature* CommentsThis field is for validation purposes and should be left unchanged.