ACS Caregiver Application

Instructions: Please read carefully. Every item below must be answered to the best of your ability. Your qualifications will be carefully reviewed and you will be given thorough consideration for any suitable openings. Upon submission, this application will become part of your personnel record with Accredited Caregiver Specialists (ACS). Please keep this in mind as you complete it.

Accredited Caregiver Specialists does not discriminate on the basis of race, color, religion, sex, national origin, citizenship, age, marital status, or disability.
If you are having difficulty filling out the application, please call (415) 564-4920 for assistance.

* = indicates a required field

Application

First Name:*	First name required.	Last Name:* Last name required.		MI:
Social Security:		Birthdate:* Birthdate required.
Phone 1:*	Phone required.	Phone 2 (Optional):
Email:*	Email required.

Address 1:*	Address required.
Address 2:
City:*	City required.	State:* State required.	Zip:* Zip required.

DISCLAIMER: Our agency conducts local and national criminal background checks. By submitting your application, you authorize ACS to conduct any and all background screening and past employment history as necessary.

Authorization required. Please make a selection.

Preliminary Questions

Have you ever worked for or applied for work with Accredited Caregiver Specialists previously?
Have you had any experience related to caregiving?
	If yes, please explain:
Are you currently certified as a CNA? (Certification is not required for registration with our company.)
Do you have any other certifications or licenses?
If yes, please list them in the space provided:
Do you speak a foreign language?
	If yes, please list them in the space provided:
Type of employment sought:		Live-in Overnight Hourly Full-Time	Hourly Part-Time On-Call
When are you available for work?		Days Nights Weekends Holidays
What is the best time to reach you?
Please indicate the hours that you are available to work for the following days:		Monday	to
		Tuesday	to
		Wednesday	to
		Thursday	to
		Friday	to
		Saturday	to
		Sunday	to
Are you available for live-ins?
If so, what days?		Monday Tuesday Wednesday Thursday Friday Saturday Sunday
How did you hear about Accredited Caregiver Specialists?
Have you ever been convicted of a crime other than a minor traffic violation?
If yes, please explain:
Do you own a car?
Do you have a current drivers license?
Are you available to drive a clients car?
Do you own a cell phone?
Do you have a current TB test with results?

Employment History

Please list your previous places of employment in chronological order, beginning with your current or most recent employer.

1.	Job Title:	Employer:
	Address:
	City:	State:	Zip:
	Phone:	Supervisor:
	Dates worked:	Hours worked (per week):
	Description of duties:

	Reason for leaving:

2.	Job Title:	Employer:
	Address:
	City:	State:	Zip:
	Phone:	Supervisor:
	Dates worked:	Hours worked (per week):
	Description of duties:

	Reason for leaving:

3.	Job Title:	Employer:
	Address:
	City:	State:	Zip:
	Phone:	Supervisor:
	Dates worked:	Hours worked (per week):
	Description of duties:

	Reason for leaving:

4.	Job Title:	Employer:
	Address:
	City:	State:	Zip:
	Phone:	Supervisor:
	Dates worked:	Hours worked (per week):
	Description of duties:

	Reason for leaving:

5.	Job Title:	Employer:
	Address:
	City:	State:	Zip:
	Phone:	Supervisor:
	Dates worked:	Hours worked (per week):
	Description of duties:

	Reason for leaving:

Professional References A minimum of three (3) professional references are required.

Name:	Phone:	Relationship:
Name:	Phone:	Relationship:
Name:	Phone:	Relationship:
Name:	Phone:	Relationship:
Name:	Phone:	Relationship

I certify that all information is true and correct to the best of my knowledge and give Accredited Caregiver Specialists permission to check all previous places of employment and references.
Full Name:		Date:
IMPORTANT: You will be presented with a confirmation page upon completion. If you are not immediately directed to a confirmation page, please scroll up to review all required fields (marked with *)before submitting application.