Application Form

Personal Information

First Name *

Last Name *

Home Phone *

Work Phone

Mobile Phone

Email *

Address 1 *

Address 2

City *

State

Zip *

Driver's License Number

Section 1 - General Information

How did you hear about Seniors Helping Seniors? (required)

Date Available? (required)

Job Type? (required)

Can you provide documentation of a driver's license and auto insurance? (required)

Yes No

Drivers License Expiration Date:

Auto Insurance Expiration Date:

Do you have a reliable car? (required)

Yes No

Desired number of weekly hours (required)

(Numeric Answer Only)

Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in Pennsylvania or any other state? (required)

Yes No

If yes, please explain.

Section 2 - Employment Verification

Are you a U.S. citizen? (required)

Yes No

If you are not a U.S. citizen, please indicate VISA type and number.

Are you authorized to work in the U.S.? (required)

Section 3 - Education

Name of High School: (required)

Location of High School: (required)

Did you graduate? (required)

Yes No

Years Attended (From/To): (required)

Additional Education (vocational, undergraduate, etc.)

Yes No

If yes, please list the name of the school and years attended (From/To)

Section 4 - Other Training/Pertinent Information

Certifications/Licenses:

Why do you want to work for SHS?

List any volunteer work you have done:

Section 5 - Current Employment

Current Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Describe Your Responsibilities:

Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

May we contact?

Yes No

Section 6 - Employment History

Last Employer:

Address:

City:

State:

Zip Code:

Start Date:

End Date:

Hours Worked:

Position/Title:

Describe Your Responsibilities:

Supervisor's Name/Title:

Supervisor's Phone:

Reason for Leaving:

May we contact?

Yes No

Section 7 - Personal Reference 1

Name: (required)

How do you know this person? (required)

Phone: (required)

Section 8 - Personal Reference 2

Name: (required)

How do you know this person? (required)

Phone: (required)

Section 9 - Personal Reference 3

Name:

How do you know this person?

Phone:

Section 10 - Emergency Contact Information

First Name: (required)

Last Name: (required)

Address:

City:

State:

Zip Code:

Phone 1: (required)

Phone 2:

Relationship: (required)

Section 11 - Services You Will Provide

Companionship/Socialization

Yes No

Meal Preparation / Planning

Yes No

Light House Cleaning

Yes No

Transportation

Yes No

Mobility Assistance

Yes No

Personal Grooming/Dressing

Yes No

Bathing Assistance

Yes No

Toileting

Yes No

Pet care/Pet walking

Yes No

Packing/Unpacking From Moving

Yes No

Handyman Services / Small Repairs

Yes No

Yard Work

Yes No

Overnight Supervision

Yes No

Dementia/Alzheimers Care

Yes No

Section 12 - Availability/Limitations

Monday

Yes No

Tuesday

Yes No

Wednesday

Yes No

Thursday

Yes No

Friday

Yes No

Saturday

Yes No

Sunday

Yes No

Hours available

Any concerns working around pets?

Yes No

Any concerns working in a smoking environment?

Yes No

Any physical restrictions or limitations?

Yes No

Section 13 - Verification/Signature

Resident of PA for ___ years: (required)

(Numeric Answer Only)

If PA resident less than 2 years, provide previous state of residence:

"I certify that the facts contained in this application are true, accurate, and complete to the best of my knowledge; I understand that, if hired, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information they may have, personal or otherwise, and release all parties from all liability for damage that may result from furnishing same to you." If you agree with this statement, please electronically sign your application by typing your full name. (required)

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.

Signature

Seniors Helping Seniors Application Form

Personal Information

Section 1 - General Information

Section 2 - Employment Verification

Section 3 - Education

Section 4 - Other Training/Pertinent Information

Section 5 - Current Employment

Section 6 - Employment History

Section 7 - Personal Reference 1

Section 8 - Personal Reference 2

Section 9 - Personal Reference 3

Section 10 - Emergency Contact Information

Section 11 - Services You Will Provide

Section 12 - Availability/Limitations

Section 13 - Verification/Signature