ANGELS BY YOUR SIDE, INC.
Non-Medical Home Care
50 North Walkup Avenue Crystal Lake, IL 60014
Phone [815] 459-2710 or 2722 Fax [815] 459-2830
APPLICATION FOR EMPLOYMENT
PERSONAL INFORMATION DATE:________________
Last Name: _______________________ First Name:_____________________________ M. I.:__________
Maiden Name: _______________________ Nickname: _________________________
Home Phone [ ]______________ Work Phone [ ]______________ Cell # [ ]_________________
Address: _____________________ Apt. #______ City_________________ State__________ Zip_________
Are you 18 years or older? _____YES _____NO
Social Security Number: ___________________________ Driver’s License #: ________________________
CIRCLE DESIRED EMPLOYMENT Caregiver Scheduler Office
Date Available: __________Salary Desired:__________ Are you employed now? YES NO
If so, may we contract your present employer? YES NO
Ever applied or worked for this company before? YES NO When?__________________
Are you authorized to work in the United States? YES NO
If hired, can you prove that you are legally permitted to work in the US? YES NO
Who referred you to this company? Newspaper Advertising Friend Walk-In
Employment Agency: ______________________ Other: _______________________
AVAILABILITY: To best accommodate you, please write in your specific hours
Days Evenings Nights 24 hr live-in Weekends On-call
Monday: __________________________________________________________________________________
Tuesday: __________________________________________________________________________________
Wednesday: _______________________________________________________________________________
Thursday: _________________________________________________________________________________
Friday: ____________________________________________________________________________________
Saturday: _________________________________________________________________________________
Sunday: ___________________________________________________________________________________
ANGELS BY YOUR SIDE, INC. EMPLOYMENT APPLICATION PAGE 2
EDUCATION
School Level Name/Location of School Yrs. Attended Did you graduate? Subjects Studied
GRAMMER YES NO
HIGH SCHOOL YES NO
COLLEGE YES NO
TRADE/BUS. YES NO
GENERAL: Please list areas of special study, training, skills, interests & hobbies
_________________________________________________________________________________________
CURRENT & FORMER EMPLOYERS
Name of Current Employer: Phone: [ ] ______
Address: City: State: Zip: ________
Starting Date: Leaving Date: Job Title: ______
Hourly Starting Salary: Hourly Final Salary: ______
Name of Supervisor: Title: ______
Description of work: ______
________________________________________________________________________________________
Have you been disciplined during your employment? YES NO ______
If YES, please explain: ______
_________________________________________________________________________________________
_________________________________________________________________________________________
______
Name of Former Employer: Phone: [ ] ______
Address: City: State: Zip: ______
Starting Date: Leaving Date: Job Title: ______
Hourly Starting Salary: Hourly Final Salary: ______
Name of Supervisor: Title: ______
Description of work: ______
________________________________________________________________________________________
Have you been disciplined during your employment? YES NO ______
If YES, please explain: ______
Reason for leaving? ______
______
________________________________________________________________________________________
ANGELS BY YOUR SIDE, INC. EMPLOYMENT APPLICATION PAGE 3
Name of Former Employer: Phone: [ ] ______
Address: City: State: Zip: ______
Starting Date: Leaving Date: Job Title: ______
Hourly Starting Salary: Hourly Final Salary: ______
Name of Supervisor: Title: ______
Description of work: ______
________________________________________________________________________________________
Have you been disciplined during your employment? YES NO ______
If YES, please explain: ______
Reason for leaving? ______
______
________________________________________________________________________________________
Name of Former Employer: Phone: [ ] ______
Address: City: State: Zip: ______
Starting Date: Leaving Date: Job Title: ______
Hourly Starting Salary: Hourly Final Salary: ______
Name of Supervisor: Title: ______
Description of work: ______
________________________________________________________________________________________
Have you been disciplined during your employment? YES NO ______
If YES, please explain: ______
Reason for leaving? ______
______
________________________________________________________________________________________
REFERENCES: List 4 persons, (NOT) Employers and Relatives you have known at least 1 Year
NAME RELATIONSHIP TO YOU PHONE # YRS. KNOWN
1.
2.
3.
4.
SERVICE RECORD BRANCH OF SERVICE: ____________________________________________
From: __________To: __________ Honorable Discharge ? YES_________ NO_________
IF NO_______EXPLAIN: _____________________________________________________________________
__________________________________________________________________________________________
Duties: ___________________________________________________________________________________
ANY ANIMAL ALLERGIES? NO YES IF “YES”, EXPLAIN ____________________________________
LATEX OR OTHER SKIN ALLERGIES? NO YES IF “YES”, EXPLAIN REACTION(S) ________________
__________________________________________________________________________________________
ANGELS BY YOUR SIDE,INC. EMPLOYMENT APPLICATION PAGE 4
HAVE YOU BEEN COVICTED OF A CRIME, OTHER THAN MINOR
TRAFFIC VIOLATIONS IN ILLINOIS? NO YES IF YES, EXPLAIN: ___________________________
HAVE YOU BEEN CONVICTED OF A CRIME, OTHER THAN MINOR
TRAFFIC VIOLATIONS IN ANY OTHER STATE? NO YES IF YES, EXPLAIN: ___________________
HAVE YOU EVER BEEN ACCUSED, ARRESTED, OR CONVICTED OF SEXUAL MOLESTATION IN ILL. ?
NO YES WHEN? ________________ WHERE? ____________________________________________
OTHER STATE? NO YES WHEN? _______________ WHERE? ________________________________
NOTE: CONVICTION OF A VIOLATION OF THE LAW IS NOT AN AUTOMATIC BAR
TO EMPLOYMENT. EACH CASE IS CONSIDERED ON ITS OWN MERIT.
APPLICANT AUTHORIZATION PLEASE READ CAREFULLY
“I certify that the facts contained in this application, and accompanying resume, if any, are true
and complete to the best of my knowledge. I understand that, if employed, falsified statements
on this application will be grounds for termination from Angels By Your Side, Inc.
I authorize a criminal background check as well as an investigation of all statements contained
in this application regarding my school/work history as well as references to obtain information
on their experiences with me. If hired, I agree to a criminal background check and to be finger-
printed. Upon termination, I authorize the release of reference information to potential
employers.”
DATE: ________________ APPLICANT SIGNATURE: ________________________________
ANGELS BY YOUR SIDE, INC. IS AN EQUAL OPPORTUNITY EMPLOYER
All qualified candidates receive consideration for employment without regards to race, color,
Religion, national origin, ethnicity, sex sexual orientation, age, the presence of an
accommodatable medical condition or disability, veteran status, or other categories protected
by law.