At Home With You, it is our mission to provide heartfelt care and assistance, making seniors' lives more comfortable. We specialize in providing in-home care assistance with activities of daily living, such as meal preparation, bathing, grooming, light housekeeping, companionship, assistance to medical appointments, medication reminders, exercise and activity, as well as geriatric care assessment and management. If you are a skilled, dedicated and compassionate caregiver with senior care experience, who would like to make a difference in providing in-home care to the elderly, please fill out the form below.

HOME WITH YOU ONLINE EMPLOYMENT APPLICATION * Required Fields First Name: * Last Name:* Address:* City:* State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip: Phone:* E-mail:* Cell: Best time to call: Desired Position:* Select... Home Care Aid Nurse Other If Other: Do you have experience working in home care? Yes No If so, was experience gained working for an agency? (List job in prior employment section): Yes No If so, was experience gained working for an individual? (List name, address, phone in prior employment section): Yes No EMPLOYMENT HISTORY Please list chronologically, beginning with most recent experience. Employer 1: Address/City: From (MM/YYYY): To (MM/YYYY): Supervisor: Phone: Salary: Type of Work: Reason for Leaving: Employer 2: Address/City: From (MM/YYYY): To (MM/YYYY): Supervisor: Phone: Salary: Type of Work: Reason for Leaving: Employer 3: Address/City: From (MM/YYYY): To (MM/YYYY): Supervisor: Phone: Salary: Type of Work: Reason for Leaving: EDUCATION Name & Location of School Select Last Year Completed Major Course Diploma/Degree High School Select... 7 8 9 10 11 12 College/University Select... 1 2 3 4 More Select... Bachelors Masters Doctorate Other None College/University Select... 1 2 3 4 More Select... Bachelors Masters Doctorate Other None Business or Trade School OTHER TRAINING Homemaking Date: City, State: Personal Care Homemaking Date: City, State: Home Health Aide Date: City, State: Companion Date: City, State: Chore Date: City, State: Certified Nursing Assistance Date: City, State: Supportive Home Care Aide Date: City, State: Medical Assistant Date: City, State: MAP Training/Other Medication Management Date: City, State: Human Service Provider / Mental Health Worker Date: City, State: PERSONAL INFORMATION Are you legally authorized to work in the U.S.?: (If hired, you will be required to provide proof of work authorization.) Yes No Are you at least 18 years of age?: Yes No Briefly describe skills you may have that you acquired in other employment or armed forces: Have you ever been convicted of a crime (felony)?: Yes No If yes, give details: (All potential employees will have to pass a CORI) Do you have any other skills you wish to mention?: Are you presently employed?: Yes No Name and phone number of current employer: If so, may we contact your present employer?: Yes No If hired, when would you be available to start?: EMPLOYMENT REFERENCES List individuals familiar with your job qualifications (No relatives or personal friends). 1) Name of Reference: 2) Name of Reference: Occupation: Occupation: Address: Address: City/State/Zip: City/State/Zip: Phone: Phone: Relationship: Relationship: How long known: How long known: How Were You Referred To This Job: Select... Advertisement School/College State Job Service Employee Referral Employment Agency Temporary Agency Government Agency Walk-In Recruiter Other   Please read carefully before submitting your application All information contained in this application is true and correct to the best of my knowledge and belief. I understand that misrepresentations or omissions of any kind may result in denial of employment or be cause for subsequent dismissal if I am hired. I authorize the company to investigate my responses on this application and contact any or all of my former employers or any individuals familiar with me or my employment background for the purpose of verifying any information I have provided and/or for the purpose of obtaining any information, whether favorable or unfavorable, about me or my employment. I voluntarily and knowingly fully release and hold harmless any person or organization that provides information pertaining to me or my employment. I understand that upon receiving a job offer, a physical examination and drug screening may be required. (Note: If this is a job requirement, you will be notified.) Regardless of whether or not I become employed by the company, I recognize that this application is not and should not be considered a contract of employment. I understand that employment at the company is on an at-will basis and that my employment may be terminated with or without cause, and without notice, at any time, at my option or the company's unless specifically provided otherwise in a written employment contract. I further understand that no company employee or representative has the authority to enter into a contract regarding duration or terms and conditions of employment other than an officer or official of the company, and then only by means of a signed written document. We have a policy of no smoking on the premises. INITIAL this box to certify that you have read and accept the above statement.