About us
Compassionate Care Services
Job Application Form
(Forte Wayne Office)
Step
1
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5
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APPLICANT IDENTIFICATION
First name
(Required)
Middle name
Last name
(Required)
Maiden name
Social Security
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Marital Status
(Required)
Single
Married
Divorced
Widowed
CONTACT INFORMATION
Your Email Address
(Required)
Enter Email
Confirm Email
Home Phone
(Required)
Cell Phone
(Required)
Address
(Required)
Street Address
City
State
Zip
EMERGENCY CONTACT INFORMATION
Emergency Contact
(Required)
Phone
(Required)
Relationship
(Required)
POSITION INFORMATION
Position You're Applying For
(Required)
Homemaker
Home Care Companion
Personal Care Attendant
Other
Desired Status:
(Required)
Full-time: 30+ Hrs/Wk
Part-time: Hrs/Wk
Desired Compensation ($) Per Hour
(Required)
Days You are available to work
(Required)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Select All
Date Available to Start
(Required)
Start Immediatly
2 Weeks from Hire
Other Date
Ready to start Date
Please tell us your desire date to start
MM slash DD slash YYYY
If you are under 18 years of age, can you provide required proof of your eligibility to work?
(Required)
Yes
No
Have you ever filed an application with us before?
(Required)
Yes
No
If yes, give date of application
(Required)
MM slash DD slash YYYY
Have you ever been employed with us before?
(Required)
Yes
No
If yes, date last employed with us
(Required)
MM slash DD slash YYYY
Are you currently employed?
(Required)
Yes
No
Are you currently on layoff status and subject to recall?
(Required)
Yes
No
Are you prevented from lawfully becoming employed in this country because of visa or immigration status?
(Required)
Yes
No
Have you ever been convicted of a crime within the last seven years?
(Required)
Yes
No
If yes, please explain below the number of convictions
Date(s) of the offense(s)
MM slash DD slash YYYY
Nature of each offense(s) leading to conviction(s)
Type(s) of rehabilitation
Can you travel if a position requires it?
Yes
No
Do you have reliable means of transportation to/from work?
Yes
No
Do you have a valid driver’s license?
Yes
No
Driver’s license number
Expiration Date
MM slash DD slash YYYY
State of Issue
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Have you ever been in the Armed Forces?
(Required)
Yes
No
If yes, please describe
Have you ever been or are you now a member of the National Guard?
(Required)
Yes
No
If yes, state entered discharge date
MM slash DD slash YYYY
REFERENCES
Referees
Provide information requested below for 3 references who are not related to you. Professional references are preferred; academic references are permitted.
Please use the + button to add more row.
Name and Date
Phone No
Time Known
Relationship
Add
Remove
Licensure
Please use the + button to add more row.
Licensed As
State or Issue
License Number
Date of Initial Licensure
Date of Expiration
Add
Remove
Education History
(Starting with High School) (Location:City/State)
Please use the + button to add more row.
School Name
Location
Years Completed
Degree Awarded/Major
Add
Remove
Consent
I, the undersigned, grant my consent to Compassionate Care Services to request that a criminal background check be performed through the Indiana Department of State Police for data related to any criminal conviction obtained against me. I, the undersigned, understand that conviction for or being presently charged with any crimes may prevent me from being eligible for employment at Compassionate Care Services.
Consent Date
(Required)
MM slash DD slash YYYY
WORK HISTORY
List your work experience for the past five years starting with your most recent job. Attach additional sheets if necessary.
If you are currently employed, may we contact your current employer?
Yes
No
Your Previous Employers
Please use the + button to add more row.
Employer
Phone No
City/state
Position
Last Supervisor
Employed From (Date)-To(Date)
Starting Pay ($)
Final Pay ($)
Reason for Leaving (be specific)
List duties performed, skills used or learned, and advancements of promotions
Add
Remove
Date
MM slash DD slash YYYY
Upload Your Resume
(Required)
Upload your resume in .pdf, .doc or .docx format
Drop files here or
Select files
Accepted file types: pdf, doc, docx, xls, xlsx, xlsm, xltx, Max. file size: 25 MB.
Attestation
(Required)
I attest that the education history, job history, and other information included in this application is true and accurate..
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