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Application Page

Please enter all relevant personal information in the fields below.

First Name:
Middle Initial:
Last Name:
Mailing Address
Apt:
City:
State:
ZIP Code:
Date of Birth
Home Phone
Cell Phone
Other Phone
Cell Phone Carrier
E-Mail Address:
Marital Status
Social Security Number
How did you hear about this opportunity?
Have you ever been referred by Dependable?
If YES, please give the dates
Do you have any friends or relatives referred by this agency?
If YES, please list his or her name:
Are you a smoker?
Do you have a vehicle?
Are you interested in being a child care worker?
Will you work with cats on the premises?
Will you work with dogs on the premises?
Have you ever been convicted of a crime other than a traffic violation?
If YES, please explain:
Have you worked under any other names (maiden name, nickname, etc.) that would help us check your work record?
What makes this particular type of work appealing to you?
Emergency Contact Name
Emergency Contact's Relationship to You
Emergency Contact's Phone Number
Please indicate the locations in which you are able to be referred (check all that apply).	Abita Springs Chalmette Covington Kenner Lacombe Madisonville Hammond Laplace Mandeville Metairie New Orleans Slidell Westbank
Indicate the times you are seeking on a regular basis: (Check all that apply)	12AM – 8AM 7AM – 3PM 7AM – 5PM 7AM – 7PM 3PM – 11PM 7PM – 7AM Any 4 hours in the Morning Available Any Time
Please indicate any other times you are available on a regular basis.
Would you work in? (Check all that apply)	Private Home Nursing Home Hospital Assisted Living
Do you have experience with? (Check all that apply)	Peg Tubes Catheters Hoyer Lifts Lifting Patients Paralyzed Patients Psych Patients Alzheimer's Patients Trach Tubes Parkinson's Colostomy Bag Placing Clients in Wheelchair
Would you perform? (Check all that apply)	Errands Empty Beside Commodes Escort to Appointments Bathing Meal Preparation Light Housekeeping Cooking for Clients
Would you transport clients in your own vehicle?	YES NO
If YES, would you be able to provide proof of insurance at the client's request?	YES NO
Are you a Certified Nurse's Aide (CNA)?	YES NO
If YES, what is your license number?
Are you a Licensed Practical Nurse (LPN)?	YES NO
If YES, what is your license number?
Are you an Emergency Medical Technician (EMT)?	YES NO
Are you a Medical Technician (Level 1)?	YES NO
Are you a Personal Care Attendant (PCA)?	YES NO
Are you a Registered Nurse (RN)?	YES NO
Do you speak any languages other than English?	Spanish French
Please list any additional information (including any special skills, equipment, or certifications) which may be helpful to us in considering your application, for example, experience with a Hoyer lift.
Did you attend high school?	YES NO
If YES, did you graduate?	YES NO
What high school did you attend?
Did you attend community college?	YES NO
If YES, did you graduate?	YES NO
What community college did you attend?
Did you attend a technical training school?	YES NO
If YES, did you graduate?	YES NO
What technical training school did you attend?
Did you attend college?	YES NO
If YES, did you graduate?	YES NO
What college did you attend?
Work History Please list your last 5 years of employment. Please begin with your current or most recent position.
Most Recent Position — All Information must be complete.
Employer:
Start Date of Employment:
Final Day of Employment
Supervisor:
Address:
Phone:
Starting Salary:
Ending Salary:
Job Title
Reason for Leaving
Work Performed / Duties
Second Most Recent Position
Employer:
Start Date of Employment:
Final Day of Employment:
Supervisor:
Address:
Phone:
Starting Salary:
Ending Salary:
Job Title:
Reason for Leaving:
Work Performed / Duties
Third Most Recent Position
Employer:
Starting Date of Employment:
Final Date of Employment:
Supervisor:
Address:
Phone
Starting Salary
Ending Salary
Job Title
Reason for Leaving:
Work Performed / Duties
Fourth Most Recent Position
Employer:
Starting Date of Employment:
Final Date of Employment:
Supervisor:
Address:
Phone:
Starting Salary:
Ending Salary:
Job Title
Reason for Leaving
Work Performed / Duties
Please be sure you have listed your last 5 years of employment. If not, you can send this information to info@dependablecare.net
I certify that all information given herin is true and correct to the best of my knowledge. I authorize any investigation of all statements and information contained in this application for referral which is necessary in arriving at a placement decision. DNFC, Inc. reserves the right to refuse any applicant for placement. ELECTRONIC SIGNATURE:
Please print your first and last name.
Please print today's date.

Since 1969, Dependable in Home Care has served over 78,000 families.

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