PERSONAL INFORMATION

First Name: *

Middle Initial:

Last Name: *

Soc Sec #: *

Date of Birth: *

Street Address: *

City: *

State: *

Zip Code: *

Email Address:

Phone: (Home) *

Phone: (Cell)

Phone: (Work)

What days are you available to work? *

What times are you available to work? *

Mornings

Afternoons

Evenings

Nights

Who referred you to this position?

(Please provide name and employer)

EMPLOYMENT INFORMATION

Current Occupation:

You must fall into one of the following three categories to be eligible for the apprenticeship. Supporting documentation will be required prior to program enrollment. Please select the one that best describes your current employment status: *

Dislocated worker

Incumbent worker

Unemployed

Eligibility question help

Dislocated worker: a dislocated worker is someone who has been terminated or laid-off or have received a notice or termination or lay-off from employment; or were self-employed but are now unemployed.
Incumbent worker: Incumbent workers are those who are currently employed in the healthcare industry who need training to secure full-time employment, advance their careers, or retain their current occupations. This includes low-wage workers, workers who need to upgrade their skills to retain employment, and workers who are currently working part-time.
Unemployed: Individuals who are without a job and who want and are available to work.

How many years have you been employed in a healthcare profession? *

EMPLOYMENT HISTORY

Begin with current or last job

Employer #1 (most recent):

Name of Employer:

Address:

City:

State:

Zip Code:

Phone:

Dates Employed, From:

Dates Employed, To:

Job Title:

Salary/Wage, Start:

Salary/Wage, Final:

Essential Job Duties:

Reason for Leaving:

Supervisor Name:

Supervisor Phone:

May we contact?

Yes

No

Employer #2:

Name of Employer:

Address:

City:

State:

Zip Code:

Phone:

Dates Employed, From:

Dates Employed, To:

Job Title:

Salary/Wage, Start:

Salary/Wage, Final:

Essential Job Duties:

Reason for Leaving:

Supervisor Name:

Supervisor Phone:

May we contact?

Yes

No

Employer #3:

Name of Employer:

Address:

City:

State:

Zip Code:

Phone:

Dates Employed, From:

Dates Employed, To:

Job Title:

Salary/Wage, Start:

Salary/Wage, Final:

Essential Job Duties:

Reason for Leaving:

Supervisor Name:

Supervisor Phone:

May we contact?

Yes

No

EDUCATION

Highest school grade completed (K-12): *

Number of years of full time post secondary education: (college, technical school, vocational school)

Medical credentials and other certificates earned : (select all that apply) *

OTHER INFORMATION

Do you currently hold any credentials/certificates? *

Yes

No

Do you have a criminal record (juvenile or adult)? *

Yes

No

Do you have a reliable mode of transportation or do you travel by bus/other mass transit? *

Personal transportation

Bus/mass transit

Are you proficient in written and spoken English? *

Yes

No

Are you proficient in any other languages? *

Yes

No

Home care work can require extensive standing, reaching, stair-climbing, moving, carrying and lifting (as many as 50 pounds or more.) Are you physically able to perform the duties of this position? *

Yes

No

Are you a veteran of the U.S. Military or the spouse of a veteran? (please read below and indicate whether you are eligible, you may be eligible for priority service if you fall into this category) *

Yes

No

Veteran Status Help

A veteran is an individual who served at least one day in the active military, naval, or air service, and who was discharged or released under conditions other than dishonorable, as specified in 38 U.S.C. 101(2). Active service includes full-time Federal service in the National Guard or a Reserve Component.
OR
An individual who is:
a) the spouse of any veteran who died of a service-connected disability;
b) the spouse of any member of the Armed Forces serving on active duty, who at the time of application for the priority, is listed in one or more of the following categories and has been so listed for a total of more than 90 days: i) missing in action; ii) captured in the line of duty by a hostile force; or iii) forcibly detained or interned in the line of duty by a foreign government or power;
c) the spouse of any veteran who has a total disability resulting from a service-connected disability, as evaluated by the Department of Veterans Affairs; or
d) the spouse of a veteran who died while a disability so evaluated was in existence.

Gender: *

Male

Female

Prefer not to answer

Race/Ethnicity: *

Hispanic/Latino

Non-Hispanic/Non-Latino

American Indian or Alaska Native

Asian

Black or African American

Hawaiian Native or other Pacific Islander

White (Caucasian)

Other

Prefer not to answer

SIGNATURE

I certify that answers given in this application are true and complete to the best of my knowledge. I authorize investigation into all statements I have made on this application as may be necessary for reaching an employment decision. Acceptance into the Apprenticeship program does not guarantee employment with any Home Health Agency. Final acceptance into the Apprenticeship program is contingent upon hire from a Home Health Agency as a Home Care Aide. In the event I am employed, I understand that any false or misleading information I knowingly provide in my application or interview(s) may result in discharge and/or legal action. I understand also that if employed, I am required to abide by all rules and regulations of the employer and any special agreements reached between the employer and me.

Check here to signify understanding: *

OK