Careers Form

Applicant Information

* = Required Information

Gender*

Male

Female

Applicant Name *
Last Name

First Name

Middle Name

Other names under which employment may be verified:

Your Home Address*

Street Address

Unit / Suite Number

State

City

Zip Code

Your Email Address*
Enter Email

Confirm Email

Home Phone

Mobile Phone*

Alternate Phone

If hired I'll be able to provide my social security number*

Yes

No

Rate of pay desired*

Have you ever worked for us before?*

Yes

No

If yes, when?

If no, how did you hear about us

Emergency Contact Name *

Emergency Phone*

Emergency Alternate Phone

Emergency Contact Relationship *

Do you have a Valid Driver's License? *

Yes

No

Do you own a car or have access to a car to drive? *

Yes

No

If yes, please be prepared to provide proof of auto insurance.

Can you work with a client who has or lives with?

Family*

Yes

No

Cats*

Yes

No

Dogs*

Yes

No

Smoking*

Yes

No

Hospice*

Yes

No

Languages Please list any languages you speak besides English.

Licenses & Certifications

Please indicate any licenses, certifications, and specializations. You will be required to provide copies of your professional certifications.(Check all that apply)

Certified Nursing Assistant (C.N.A.)*

Yes

No

Expires On

School Received Certification

Personal Care Assistant (P.C.A.)*

Yes

No

Expires On

School Received Certification

Certified Home Health Aide (C.H.H.A.)*

Yes

No

Expires On

School Received Certification

CPR Certification*

Yes

No

Expires On

Facility Received Certification

First Aid Certification*

Yes

No

Expires On

Facility Received Certification

Basic Life Support Certification (BLS)*

Yes

No

Expires On

Facility Received Certification

Name of Certification

Expires On

Facility Received Certification

Name of Certification

Expires On

Facility Received Certification

Have any of your licenses or certifications been suspended or revoked?*

Yes

No

If yes, please describe

Do you have any caregiver training from other home services agencies?*

Yes

No

If yes, from where?
If yes, please be prepared to provide proof of training.

Have you ever been convicted of a felony or misdemeanor?*

Yes

No

If yes, please describe

If hired, would you be able to provide proof of authorization to work in the U.S.?*

Yes

No

How many years have you worked as a professional caregiver?*

What percent of your previous case work has been for an agency?*

Please explain how you will contribute to strengthen the 3 Cross Home Care Corp. team:*

Please share one or more personal or professional experiences you have had as a caregiver:*

Availability

Please check the appropriate boxes to indicate your availability for work.

Days*

Yes

No

Nights*

Yes

No

Weekends*

Yes

No

Live-in*

Yes

No

Are there any limitations or commitments that would prevent you from working?*

Can you travel outside the city of Chicago to work?*

Yes

No

Education

Please indicate the levels of education you have completed.

High School

City and State

Did you graduate?

Yes

No

Subjects Studied

College

City and State

Did you graduate?

Yes

No

Degree

Other

City and State

Did you graduate?

Yes

No

Degree

Please list any special awards you were given or courses you have taken:

Military Service

U.S. Military or Naval Service:*

Yes

No

Rank at Discharge:

Employment History

List your employers starting with the most recent. Please account for all periods of not-working in the space provided at the end of this section.

Company Name:*

Phone:*

Address:*

Supervisor:*

Street Address

State

City

Zip Code

Job Title:*

Salary or Rate of Pay:*

Responsibilities*

From*

To*

Reason for Leaving*

May we contact this employer?*

Yes

No

Company Name:*

Phone:*

Address:*

Supervisor:*

Street Address

State

City

Zip Code

Job Title:*

Salary or Rate of Pay:*

Responsibilities*

From*

To*

Reason for Leaving*

May we contact this employer?*

Yes

No

Company Name:*

Phone:*

Address:*

Supervisor:*

Street Address

State

City

Zip Code

Job Title:*

Salary or Rate of Pay:*

Responsibilities*

From*

To*

Reason for Leaving*

May we contact this employer?*

Yes

No

Company Name:*

Phone:*

Address:*

Supervisor:*

Street Address

State

City

Zip Code

Job Title:*

Salary or Rate of Pay:*

Responsibilities*

From*

To*

Reason for Leaving*

May we contact this employer?*

Yes

No

Please explain any gaps in your work history

Character References

Give below the names of three persons not related to you, whom you have known at least one year.

Name*

Phone*

Address*

Relationship*

Street Address

State

City

Zip Code

Name*

Phone*

Address*

Relationship*

Street Address

State

City

Zip Code

Name*

Phone*

Address*

Relationship*

Street Address

State

City

Zip Code

Upload Resume
(optional)

Accepted file types: pdf, doc, docx, txt.

Additional Notes
Please feel free to include any additional notes or comments with your application.

Disclaimer and Signature

I certify that the information contained in this application is true and correct to the best of my knowledge and I understand that falsification of this information is grounds for refusal to hire or, if hired, termination of my employment. I agree that my employment is at-will and may be terminated (or an offer of employment may be withdrawn) by 3 Cross Home Care Corp. at any time, with or without cause, and with or without prior notice. I understand if hired, I will be required to produce documentary evidence proving that I am currently authorized to work in the United States. I also understand my continued employment is contingent upon providing proof of continuing work authorization upon expiration of any documents provided at time of hire. I understand that periodic drug testing may be required as a condition of employment and continued employment. I authorize 3 Cross Home Care Corp. investigation of all statements contained herein. I hereby authorize 3 Cross Home Care Corp. to conduct a criminal background investigation and to contact my references. I hereby authorize such references to give 3 Cross Home Care Corp. any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise. I hereby release 3 Cross Home Care Corp., its shareholders, officers, directors, employees and agents from any and all liability for any damage that may result from the collection or utilization of such information in connection with evaluating my potential employment. I also understand and agree that no representative of 3 Cross Home Care Corp. has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to foregoing, unless it is in writing and signed by 3 Cross Home Care Corp.'s President.

Acceptance*
Entering my name in the box acts as my signature and agreement to the disclaimer

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