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Other Information
Why do you think this position is a good fit for you?
Please tell us about your family caregiving experience.
Do you already have a LEVEL II background screen through AHCA (Agency for Health Care Administration)? (If you do, please provide your Social Security Number so your eligibility can be verified in the AHCA portal.)
Please List your Driver's License Number, Issuing State, and Date of Expiration. (A valid driver's license is a requirement of the job- failure to enter this information may cause your application to not be considered.)
Please list, from the following counties in Florida that we service, where you are willing to work: Escambia, Santa Rosa, Okaloosa, Walton.
Indicate, from the following list of services we provide, what you have the skills and experience to do: Companion, Homemaker, Respite, Personal Care, Child Care.
Please specify which shifts you would be interested in: Day, Morning, Afternoon, Evening, Overnight, and/or Weekend. (Please be specific- list hours and days available. A minimum of 4 hours/week is required on Saturday or Sunday)
Do you have any issues (restrictions, allergies, fears) working in homes with clients who may: Smoke? Have pets? Require physical assistance in getting up? etc.
Have you ever been arrested, plead guilty or no contest, for charges relating to theft, violence, drugs or any crimes against vulnerable citizens?
Signature and Verification
I certify that answers given herein are true, accurate, and complete to the best of my knowledge. I authorize investigation into all statements I have made on this Form as may be necessary for reaching an employment decision. In the event I am employed, I understand that any false or misleading information I knowingly provided herein or in subsequent interviews may result in discharge and/or legal action. I understand that this Career History Form is not the sole basis from which a hiring decision has been made, and understand that this Form will be used in conjunction with a series of interviews and assessments to determine my suitability for the role to which I am applying.
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