Date: ________________________________

Name: ______________________________________________ Age: ____________________

Address: _______________________________________ City & Zip: __________________

Telephone: _________________________ Male ___ Female ___ Marital Status:_________

REFERENCES (ask for at least one from a former or current place of employment)

1. Name: _________________________________ Relationship: ______________________

Address:___________________________________ City: ________________________

Telephone: ______________________________________________

2. Name: _______________________________ Relationship: _______________________

Address:_____________________________________ City & Zip: ____________________

Telephone: ______________________________________________

Any health problems or physical restrictions?____________________________________

_________________________________________________________________________________

Do you smoke? Yes _____ No ______ Do you have a car? Yes ______ No _______

Have you ever been convicted of a crime? Yes _____ No ______

If yes explain: _________________________________________________________________

Do you have experience and/or certification as an aide? Yes ________ No _______

If yes explain:____________________________________________________________________

Are you willing to work these hours?_______________________________________________

Specify time off (if it is a live-in situation):____________________________________

Other information _________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________