Employment Application for Home Care Aide

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					                                                   WeGo4U

                     Independent Contractor Information Application
        Position:
           o Independent Contractor- Providing Personal Concierge Service (Check all that
                 apply.)

                       PLEASE PRINT CLEARLY AND ANSWER ALL QUESTIONS COMPLETELY


PERSONAL INFORMATION

Today’s Date                              Social Security #                             Date of Birth
Complete Name (LAST NAME FIRST)
       Other Surnames that I have used
Present Address
City                                                      State              Zip Code
Home Phone                                                Cell/Pager No.
Emergency Phone                                           Email Address
When can you begin work?                   How did you hear of us?
Are you currently employed?       Yes     No          If so, may we inquire of your present employer?                Yes
  No
                                  Name                             Phone#                                 Relationship to you


GENERAL INFORMATION REGARDING INDEPENDENT CONTRACTORS

Independent Contractors are responsible for all their incurred expenses and taxes. Independent
contractors are not employees of WeGo4U.
Have you ever been convicted of a crime (excluding any sealed or expunged conviction)?              Yes         No
       Explain
                           (PLEASE NOTE: A CONVICTION WILL NOT NECESSARILY DISQUALIFY YOU )
Have you ever been fingerprinted?        Yes    No Was it a LiveScan?        Yes        No Records found?            Yes
  No
Do you currently use any controlled substances (including marijuana)?             Yes    No
       Explain
Do you smoke?        Yes   No              If so, are you willing to not smoke on the job?       Yes       No
        Are you willing to contract in a smoker’s home?      Yes    No
Do you have any conditions that limit your ability to perform the specifics of an offered contract?
  Yes     No If yes, what can be done to accommodate your limitations?



Do you have adequate means of transportation to get to the contractors site on time each shift and when
called in on short notice during normal working hours?   Yes    No
Do you have a reliable vehicle?    Yes     No – Valid Driver’s License?     Yes     No – Car Insurance?      Yes           No
How many miles would you be willing to travel to a job?
                                                     WeGo4U
Is there any limitation you wish to place on the type of work you will do?
Do you have any allergies to animals        Yes    No        Will you work around pets            Yes     No
Are you willing to care for:                Female / Male / Couple (Circle all that apply.)



CONTRACTOR AVAILABILITY CHART

PLEASE, SHOW TIMES WHEN YOU ARE AVAILABLE TO CONTRACT

                               Daytime Hours                     Nighttime Hours                        Live-In/Overnights
          Saturday
          Sunday
          Monday
          Tuesday
          Wednesday
          Thursday
          Friday
Can you be called at the last minute in case of an emergency?          Yes       No
Please list times that you are NOT available to work
Comments


  (Please keep in mind that flexibility in your choice of days, hours and travel increases your potential for referral.)




QUALIFICATIONS: EDUCATION / SKILLS / CERTIFICATIONS / TRAINING

   Type of School                       Name & Location                       Circle Last Year          Graduated     Degree
                                                                                 Attended
High School                                                               9      10    11     12
College                                                                   1       2     3         4
College                                                                   1       2     3         4
Other                                                                   From: ______ To:______

List professional licenses you possess. Indicate type of license, number and state and expiration dates


List any memberships in professional organizations, honors or activities which you feel would enhance your
application
Are you certified: In CPR?        Yes      No Exp. Date:              In First Aid?         Yes       No Exp. Date:
Do you have home care experience with seniors or others?                Yes       No                  How Long?
List language(s) spoken fluently other than English:

                                                                                                                             2
                                                                   WeGo4U
List any other skills applicable to the position for which you are applying




REFERENCES (3 people NOT RELATED to you, whom you have known at least 1 year)

We require business and personal references. Two references must be work-related, with at least one in the
caregiver field. A reference may be from (1) another type of business where you have worked, (2) volunteer
work or (3) home care training. These references may be clients, clients’ relatives, supervisors or teachers.

1. Reference Name                                              Relationship                       Phone
    Address                                                                                       Known How long?

2. Reference Name                                              Relationship                       Phone
    Address                                                                                       Known How long?

3. Reference Name                                              Relationship                       Phone
    Address                                                                                       Known How long?

I authorize the references I have listed to provide all information regarding my suitability for employment. I
hereby release all persons from any liability for any damages that may result from giving information to
HomeHelpLink, Inc.
I also authorize investigation of all statements contained in this application. I understand and agree that
contracting with WeGo4U is a contract to contract basis. That is, it may be terminated at the end of each
month. Continuation of monthly contracts will be approved or denied by WeGo4U administrator.
Signature                                                                                         Date

I understand that due to the nature of certain contracts, applicants may be subject to a criminal background. I
understand I will be required to maintain proper certifications, including, but not limited to, CPR and First Aid.



                        Independent Contractor Signature                                                            Today’s Date


                             Print Name                                                                Position Applied For

         _____________                           /             /
   Social Security Number/Tax ID number        Date of Birth                  Drivers License Number                     State

Other names you have used or are known as:




This application will be valid for six months from the date completed.




                                                                                                                                   3
                                                         WeGo4U



FOR OFFICE USE:                     GENERAL REFERENCE CHECK
From:             WeGo4U                      Contact:          D. Peterson, Administrator

                                                       Phone:            937-789-9262                Fax:     937-648-2393

To: Attn: ________________________________                      _______________________________
                  Name of Reference                                      Company


              For Potential Contractor: Please read, then complete asterisked lines only
RELEASE OF INFORMATION
*                                                      *
________________________________                       _______________________________
Contractor Complete Name                               Social Security Number/Tax ID number

I acknowledge that consideration for being included in WeGo4U’s contractor pool is contingent on the result of a reference and
background check. Therefore, I hereby authorize HomeHelpLink, Incorporated dba WeGo4u (1) investigate the truthfulness of all
statements made on this contractor application; (2) contact my former employers, contractors and other listed references or any
other persons who can verify information; and (3) discuss the results of any investigation with other employees or HomeHelpLink
involved in the hiring process. In addition, I give my consent for all contacted persons including former employers to provide
information the concerning application, and I release each such person from liability for providing information to HomeHelpLink.


*                                                      *
________________________________                       _______________________________
Applicant Signature                                    Date


        For Reference: Please complete and return to HomeHelpLink at above fax number.
We appreciate your courtesy in responding to the following inquiry concerning your former employee named

                                                                                                      (applicant).

Position/Title:                               Dates of Employment: (month/year)                               to
Reason for leaving this job
Information Given By:                                                               Title:


PERFORMANCE CRITERIA
Please mark (+) for excellent and (-) needs improvement
   Punctuality / Attendance
   Reliability / Following Instructions
   Flexibility / Cooperation / Communication
   Attitude / Rapport with Older Adult and Others
   Concern for Older Adult’s Well-being
   Quality of Work: ___ Excellent ___ Good       ___ Average                      ___ Poor
   Works well with others: ___ Yes        ___ No
Is the above applicant eligible for rehire?              Yes      No
Would you recommend the applicant for similar employment?                          Yes       No

Additional Comments:

                                                                                                                               4
                                                        WeGo4U



FOR OFFICE USE:                     GENERAL REFERENCE CHECK
From:             HomeHelpLink, Inc.                   Contact:          D. Peterson, Administrator

                                                       Phone:            937-789-9262                Fax:     937-648-2393

To: Attn: ________________________________                      _______________________________
                  Name of Reference                                      Company


                      For Applicant: Please read, then complete asterisked lines only
RELEASE OF INFORMATION
*                                                      *
________________________________                       _______________________________
Contractor Complete Name                               Social Security Number/Tax ID number


I acknowledge that consideration for being included in WeGo4U’s contractor pool is contingent on the result of a reference and
background check. Therefore, I hereby authorize HomeHelpLink, Incorporated dba WeGo4u (1) investigate the truthfulness of all
statements made on this contractor application; (2) contact my former employers, contractors and other listed references or any
other persons who can verify information; and (3) discuss the results of any investigation with other employees or HomeHelpLink
involved in the hiring process. In addition, I give my consent for all contacted persons including former employers to provide
information the concerning application, and I release each such person from liability for providing information to HomeHelpLink.


*                                                      *
________________________________                       _______________________________
Applicant Signature                                    Date


        For Reference: Please complete and return to HomeHelpLink at above fax number.
We appreciate your courtesy in responding to the following inquiry concerning your former employee named

                                                                                                      (applicant).

Position/Title:                               Dates of Employment: (month/year)                               to
Reason for leaving this job

Information Given By:                                                               Title:


PERFORMANCE CRITERIA
Please mark (+) for excellent and (-) needs improvement
   Punctuality / Attendance
   Reliability / Following Instructions
   Flexibility / Cooperation / Communication
   Attitude / Rapport with Older Adult and Others
   Concern for Older Adult’s Well-being
   Quality of Work: ___ Excellent ___ Good       ___ Average                      ___ Poor
   Works well with others: ___ Yes        ___ No
Is the above applicant eligible for rehire?              Yes      No
Would you recommend the applicant for similar employment?                          Yes       No

Additional Comments:
                                                                                                                               5
                                                        WeGo4U



FOR OFFICE USE:                     GENERAL REFERENCE CHECK

From:             HomeHelpLink, Inc.                   Contact:          D. Peterson, Administrator

                                                       Phone:            937-789-9262                Fax:     937-648-2393

To: Attn: ________________________________                      _______________________________
                  Name of Reference                                      Company


                      For Applicant: Please read, then complete asterisked lines only
RELEASE OF INFORMATION
*                                                      *
________________________________                       _______________________________
Contractor Complete Name                               Social Security Number/Tax ID number

I acknowledge that consideration for being included in WeGo4U’s contractor pool is contingent on the result of a reference and
background check. Therefore, I hereby authorize HomeHelpLink, Incorporated dba WeGo4u (1) investigate the truthfulness of all
statements made on this contractor application; (2) contact my former employers, contractors and other listed references or any
other persons who can verify information; and (3) discuss the results of any investigation with other employees or HomeHelpLink
involved in the hiring process. In addition, I give my consent for all contacted persons including former employers to provide
information the concerning application, and I release each such person from liability for providing information to HomeHelpLink.


*                                                      *
________________________________                       _______________________________
Applicant Signature                                    Date


        For Reference: Please complete and return to HomeHelpLink at above fax number.
We appreciate your courtesy in responding to the following inquiry concerning your former employee named

                                                                                                      (applicant).

Position/Title:                               Dates of Employment: (month/year)                               to
Reason for leaving this job
Information Given By:                                                               Title:


PERFORMANCE CRITERIA
Please mark (+) for excellent and (-) needs improvement
   Punctuality / Attendance
   Reliability / Following Instructions
   Flexibility / Cooperation / Communication
   Attitude / Rapport with Older Adult and Others
   Concern for Older Adult’s Well-being
   Quality of Work: ___ Excellent ___ Good       ___ Average                      ___ Poor
   Works well with others: ___ Yes        ___ No
Is the above applicant eligible for rehire?              Yes      No
Would you recommend the applicant for similar employment?                          Yes       No

Additional Comments:

                                                                                                                               6
WeGo4U




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