Apply for Be an Angel; Change a Life

Please fill out the form below and click Submit to submit your application for consideration. Fields with an asterisk (*) are required.

Summary
Title:Be an Angel; Change a Life
ID:1009
Department:Caregiver
Contact Information
* First Name:
Middle Initial:
* Last Name:
* Address 1:
Address 2:
* City:
* State:
* Zip:
* Phone (Home):
* Phone (Mobile):
* Email:
Attachments
Resume:
Supported formats: Word, PDF, RTF, Text, and HTML.
  - or Upload from:
 
Visiting Angels
PERSONAL INFORMATION
Personal Information Section:
* I have the following (please select all that apply):

* Do you have a valid Driver’s License?:
Yes   No
* Do you have valid Car Insurance?:
Yes   No
* Are you comfortable providing transportation for clients in your own vehicle?:
Yes   No
* Make, Model, Year of the Car you will be using for work. If you do not have a car, please type "NA" in the box:
* Vehicle Color (if you do not have a vehicle, please type "NA" in the box):
* Do you have a clean driving record?:
Yes   No
* Do you have proof of your eligibility to work in the United States?:
Yes   No
* Are you 18 years of age or older?:
Yes   No
* Have you applied to or worked for Visiting Angels before? :
Yes   No
If yes, please explain:
* Have you ever been disciplined for violating company safety rules or regulations?:
Yes   No
If yes, please explain:
Visiting Angels pays $13 to $15 per hour based on the level of client care. Any shifts that are 1-3 hours long pay $15+ per hour.
* What is your acceptable rate of pay?:

* Why do you want to work for Visiting Angels?:
* Are you fluent in English communication? (both spoken and written):
Yes   No
* Are you fluent in any other languages?:
Yes   No
If yes, please list which languages:
* I understand that drug testing may be required.:
Yes   No
Do you have ANY allergies? (cats, dogs, food, smoke, etc.) Please list:
* What are the 3 most important characteristics a caregiver should possess?:
* How did you hear about Visiting Angels? :

EXPERIENCE
Include employment history for the last 10 years with complete name and title for each contact person. Be sure to explain any gaps in your Employment History:
Explain any gaps in employment here


Current or Most Recent Employer

Employer Name & Address Employer Phone Dates Employed

From:

To:
Job Title Supervisor Name & Title May we Contact?

Yes
No
Responsibilities Reason for Leaving Salary/Hourly Rate
Start:

End:

Employer 2

Employer Name & Address Employer Phone Dates Employed

From:

To:
Job Title Supervisor Name & Title May we Contact?

Yes
No
Responsibilities Reason for Leaving Salary/Hourly Rate
Start:

End:

Employer 3

Employer Name & Address Employer Phone Dates Employed

From:

To:
Job Title Supervisor Name & Title May we Contact?

Yes
No
Responsibilities Reason for Leaving Salary/Hourly Rate
Start:

End:

Employer 4

Employer Name & Address Employer Phone Dates Employed

From:

To:
Job Title Supervisor Name & Title May we Contact?

Yes
No
Responsibilities Reason for Leaving Salary/Hourly Rate
Start:

End:

Employer 5

Employer Name & Address Employer Phone Dates Employed

From:

To:
Job Title Supervisor Name & Title May we Contact?

Yes
No
Responsibilities Reason for Leaving Salary/Hourly Rate
Start:

End:

Employer 6

Employer Name & Address Employer Phone Dates Employed

From:

To:
Job Title Supervisor Name & Title May we Contact?

Yes
No
Responsibilities Reason for Leaving Salary/Hourly Rate
Start:

End:
REFERENCES Additional Professional References (do not include family or friends – MINIMUM of 3 required)

Reference Name Position/Title Phone Number Dates Known
*
*
*
*
*
*
*
*
*
*
*
*

CRIMINAL HISTORY
* Have you ever been convicted of any felony or misdemeanor offenses?:
Yes   No

(List any felonies or misdemeanors, including driving related offenses, misdemeanors or felonies.)

If yes, please describe the nature of the offense:

EDUCATION
Colleges/Universities/CNA or HCA Training Program or Class

Name Location Degree/Certificate Earned Graduation/Completion Date

High School

* Do you have a High School Diploma or GED?:
Yes   No

CERTIFICATIONS AND LICENSES
* Select all certifications/training that you have completed:
Credential Number for HCA or CNA or NAR, if applicable:
Please describe the certifications and/or training that you have selected above. (E.g. class start and end dates, name of school attended, etc.):
* Do you have a Nurse Delegation Certification?:
Yes   No

AVAILABILITY
* Please list the days of the week and time ranges that you are available to work for Visiting Angels each day. Please be specific::

* When can you begin work, if hired?:
* How many hours per week will you work for Visiting Angels? (In order to be considered for our team, we require a MINIMUM of 20 hours per week of availability.):
* How many 24 Hour Live-In Shifts are you available to work per week?:
* Please select the types of shifts you will accept if employed with Visiting Angels:

* Please select the locations that you are willing to travel to for work. (To be considered for hire, you must be willing to travel to a MINIMUM of 4 different cities that Visiting Angels serves.)::

SKILLS AND PREFERENCES
* I am comfortable working with (select all that apply):
* Do you have a 2nd job?:
Yes   No

If yes, please let us know your current work schedule with your other company and how many hours you are working for them.:
* Will you work with clients who smoke tobacco?:
Yes   No
* Are you a smoker?:
Yes   No

CERTIFICATION AND RELEASE
I certify that the information given by me is true and complete to the best of my knowledge. I understand that if I am employed, the discovery that I gave false information during the application process may result in immediate dismissal. I authorize Visiting Angels, to which I am providing this application to investigate all statements contained in this application and to request information about me from previous employers, educational institutions, and references. I expressly authorize my previous employers to provide information and opinions concerning my work and work habits. Further, I release all parties (including Visiting Angels) and persons connected with any requests for information from all claims, liabilities, and damages for whatever reason, arising out of furnishing any information. If employed, I release Visiting Angels from any liability for future references it may provide regarding my work history with them. I understand Visiting Angels cannot guarantee that my application will be considered for any or all open positions they may have or that my application will be considered for any specific time. In the event of employment, I understand that I am required to abide by all current and subsequently issued rules and regulations of Visiting Angels and that my employment and compensation may be terminated, at any time, with or without notice, by either party. Please enter your name and the date as certification of acceptance of these terms.

* Agree:
Yes   No

* Signature (type full name):
* Date:

RESTRICTIVE COVENANT
I agree not to do business directly with any individual or business entity that Visiting Angels has introduced to me or by entering into employment with such individuals or businesses.

* Agree:
Yes   No

* Signature (type full name):
* Date:

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