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:
* 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
* I have the following (please select all that apply):
* As part of your responsibilities working for Visiting Angels, basic computer skills and internet access are required. (please select all that apply):

Preferred Methods of Contact:
1st Preference:
2nd Preference:
3rd Preference:

Please list your Cell Phone Provider:
Driver’s License Number:
State ID Number:
* State:
* 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
Please list any motor vehicle related infractions including speeding tickets, unpaid tickets, DWLS, DUI, etc. Please include an explanation:
* 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
* Do you agree to travel up to 20 miles from your home for Visiting Angel’s Clients? :
Yes   No
* Have you applied to or worked for Visiting Angels before? :
Yes   No
If yes, please explain:
* Have you ever been disciplined or received verbal or written warnings for absenteeism or tardiness? :
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-$16.50 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?:
* What are your long-term dreams and aspirations?:
* 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
* Are you allergic to cats?:
Yes   No
* Are you allergic to dogs?:
Yes   No
Do you have ANY other allergies? (please list):
* What are the 3 most important characteristics a caregiver should possess?:
* How did you hear about Visiting Angels? :

Personality Questionnaire
* Describe a time when you had a tough problem and had not been provided with accurate information and/or training. What did you do?:
* Give me an example of how you keep track of task details and keep yourself organized.:
* Tell me about a situation when you had to be patient with a client or customer to get them to cooperate. How did you do it?:
* Have you ever shown up at a job and it wasn’t what you expected it to be? If yes, what did you do? If no, what would you do in this type of situation?:
* Tell me about a time when a client or co-worker gave you more information than you expected or wanted. How did it make you feel?:
* Tell me about a time when you felt an issue for your client was more urgent than what others believed. What did you do?:
* Tell me about a time when you were on a team that was recognized for a job well done. What was your role and how did it make you feel?:

EXPERIENCE
Include ALL WORK EXPERIENCE 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


EMPLOYER 1

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 2 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/University

Name Location Degree/Certificate Earned Graduation/Completion Date

High School

Name Location Diploma/GED Earned? Graduation/Completion Date

* Are you currently a student?:
Yes   No
If you have completed any special courses, seminars and/or training that would help you to perform the position for which you are applying, please describe:

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.):

AVAILABILITY
* Visiting Angels serves clients 24 hours per day and 7 days per week.  Please list the days of the week and time ranges that you are available to work each day.  Please be specific:
* I agree to accept shifts every other weekend during my 90 Day Probationary period.:
Yes   No

* 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 shift blocks you are available to work if offered shorter shifts. This allows us to stack shifts for longer hours per day. Please select all that apply:

* Please select a minimum of 3 areas that you are willing to travel to for work (select all that apply. You must select at least 3 to be considered for hire.):

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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