How many years of professional caregiving experience do you have?

Are you available for Hourly and/or Live-In Care? Please specify which or both.

What is your availability? Please specify what days you are available with a start and end time.

Do you have a valid drivers license?

Do you have your own reliable vehicle to transport Clients daily?

How did you hear about Home Care Assistance of Wisconsin? Please be specific. :

Home Care Assistance runs national background checks. Is there anything you would like us to be aware of?

APPLICATION RECEIPT PLEASE READ CAREFULLY BEFORE SIGNING 1. I understand that the receipt of this application does not imply that I will be employed. 2. I certify that the information provided by me in the application is true and complete. I also understand that any falsification, omission or misrepresentation made by me on this application is grounds for refusal to hire or if hired termination. 3. I authorize an investigation of all statements contained in this application and/ or the attached resume and authorize any of the persons or organizations referenced in this application to give you any and all information concerning my previous employment, education or any other information they might have, personal or otherwise, with regard to any subjects covered by this application, and I release all parties from all liability for any damage that may resulti from furnishing such information to you. 4. I understand that wages, benefits and other terms and conditions of employment may be changed from the time at your discretion without prior notice. 5. I acknowledge that you reserve the right to amend or modify your policies at any time, without prior notice. 6. I acknowledge that if I am employed by Home Care Assistance, my employment will be at will, meaning that Home Care Assistance is free to terminate my employment at any time, for any reason, with or without cause and I have the same right, to terminate my employment at any time. I understand that neither this application nor any other document given to me is intended to create, nor should the documents be construed as creating, an expressed or implied contract of employment for a defined term. RELEASE OF INFORMATION AUTHORIZATION It is the policy of Home Care Assistance to conduct reference check for employment candidates. Your signature below indicates your agreement with and acknowledgment of the following: 1. As an applicant for employment with Home Care Assistance, I authorize my current and past employers and current and past work associates to release to Home Care Assistance any reference and employment information, including but not limited to performance evaluations and attendance records and work-related personal characteristic (e.g. my character, dependability, honesty, integrity, interpersonal skills, etc.) 2. Home Care Assistance will maintain reference information in the strictest confidence and solely for the purposes of the recruitment for which I have applied. 3. A photocopy or fax of this signed Authorization is to be considered valid as an original. 4. I have carefully read and understand all of the provisions above and have voluntarily agreed to sign this authorization. My signature certifies that I have read and agree with all the above statements.