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CAREERSAdmin2022-06-24T11:44:52+00:00

EMPLOYMENT FORM

MERCY HOME CARE SERVICES EMPLOYMENT APPLICATION

Thank you for your interest in working for Mercy Home Care Services. We are looking for honest, reliable, and hardworking caregivers. Please submit the application below to join our team.

APPLICANT INFORMATION:

First Name *

Last Name *

Home Phone *

Work Phone *

Cell # *

Street Address *

Apartment, suite, etc *

City *

State/Province *

ZIP / Postal Code *

Social Security Number: *

Driver’s License #: *

DOB *

Email Address *

Insurance Company *

Policy# *

Agent’s Name: *

Telephone #: *

Were you previously employed by Mercy Home Care Services? If yes please list the date you worked and the reason for separation: *YesNo

How did you know about us? *AdvertisementFriendWalk-In WebsiteOther

If you have a cell phone may we contact you for work via text messages? *YesNo

If yes what is your cell phone carrier? *VerizonAT&TT-MobileCricket

Other *

EMERGENCY CONTACT:

Name *

Telephone: *

Address *

Relationship: *

Which times are you available to work: *

Earliest time of day you can start: *

Latest time you can end day: *

Any times not available to work: *

Please check the shifts you would prefer: *DaysEveningsOvernightsLive-In

Day and time available: *

Holidays: *7a-3p3p -11p11p – 7a

Live-in *

Do you have dependable transportation? *

Approximately how many hours per week do you wish to work? *

When are you available to begin work? *

What cities/countries can you work in? *

How far are you willing to commute to work? *

What do you like most about working with the elderly? *

What do you like least about working with the elderly? *

Discuss any training or experience working with the elderly: *

Do you have any health problems or limitations that might affect your performance on the job? *

EDUCATION:

High School: *

City *

State/Province *

Start-Date: *

End Date: *

Did you graduate: *YesNo

College *

City *

State/Province *

Dates: *

CERTIFICATION AND CREDENTIALS:

Please answer yes or no to all that apply and enter expiration dates of the certifications if applicable

CNA License *

Caregiver License *

Continued Education or on- site training *

CPR Certification *

First Aid Certification *

Tuberculosis Test *

Fingerprint Clearance card *

State ID Card *

Driver’s License *

COVID-19 Vaccine *

Flu Shot *

Please select the boxes that match your skills and preferences *

Meal PrepMedication RemindersAssist with dressingCatheter CareCompanionshipAppointment RemindersExercise RemindersEmpty Bed Pan/Urinal/CommodeFiling Nails/ToenailsCleaning/LaundryTransportation/ErrandsShavingOral HygieneSkin CareAssist with Bathing/ShowerLight House keepingMaking Occupied BedLinen ChangesAssist with WalkingTurning &/or Positioning ClientsBath/Shower TransferBed to Chair TransferHoyer Lift ExperienceSlide Board TransferToilet/Commode TransferTransfers to/from bathroomWalker/Cane AssistantWheelchair TransferAre you ok with cats?Are you ok with dogs?Feed Cat/dogLitter box CleaningVital signs-(blood pressure, pulse, respirations)

FORMER AND CURRENT EMPLOYERS:

Employer 1:

Employer Name

Street Address

City

State/Province

ZIP / Postal Code

Starting Date:

Leaving Date:

Job Title:

Name of Supervisor:

Title:

Description of work:

Have you been disciplined during your employment?Yes No

If Yes, please explain:0 / 1000

Reason for leaving?

REFERENCES:

List 3 people that are not employers or relatives that you have known for at least a year

Reference 1

Name0 / 400

Relationship to you0 / 400

Phone

Years known

Reference 2

Name0 / 400

Relationship to you0 / 400

Phone

Years known

Reference 3

Name0 / 400

Relationship to you0 / 400

Phone

Years known

List states and counties of residence for the past seven years:

Have you used any names or social security numbers other than those on this application?Yes No

If so, please describe0 / 1000

Have you been convicted of a crime, other than minor traffic violations in any state? *YesNo

If yes, which state?

Please explain0 / 1000

Have you been accused, arrested, or convicted of sexual molestation in any state? *Yes No

If yes, which state?

Please explain0 / 1000

Have you been convicted of a felony/misdemeanor and/or served time in prison in the past seven years? or any other time? *YesNo

APPLICANT AUTHORIZATION:

I certify that I have read and understood the information on this job application and that the answers given by me to the foregoing questions and the statements made my me, and any accompanying resume or documents are complete and true to my knowledge and belief. I understand that any false information, omission or misrepresentation of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize Mercy Home Care Services, LLC and/or its agents, including consumer reporting bureaus to verify any information including, but not limited to criminal history, elderly and child abuse 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. If hired, I agree to a criminal background check and to be fingerprinted. Upon termination, I authorize the release of reference information to potential employers. Also, I understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to random drug test to detect the use of illegal drugs prior to and during employment.

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DATE

INTERVIEWER COMMENT

We are committed to provide affordable in-house home care at the comfort of your home.

Contact Details

P.O. Box 895, Maricopa, AZ 85139

[email protected]

480-383-6292

520-858-2780

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Mercy Home Care Services provides affordable in-home care services to seniors

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