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Preserving Dignity Through Independence at Home
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Application for Employment - Apply Now
Please fill out the form below and click Submit to submit your application for consideration.
Contact Information
*
First Name:
*
Last Name:
City:
State:
Primary Phone:
*
Email:
Attachments
Resume:
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Application for employment
EMPLOYMENT HISTORY & WORK REFERENCES
Current or most recent Employer
From
To
Employer/Client Name
Phone
City
State
Job Title
Supervisor
Describe Your Duties
Reason You Left
Previous Employer
From
To
Employer/Client Name
Phone
City
State
Job Title
Supervisor
Describe Your Duties
Reason You Left
Next Previous Employer
From
To
Employer/Client Name
Phone
City
State
Job Title
Supervisor
Describe Your Duties
Reason You Left
Explain any gaps of employment over 6 months
If you were you referred to us by a current Companions & Homemakers caregiver please give their name
Are you eligible to work in the U.S.?
Yes
No
(All new hires will be required to provide proof of eligibility to work in the U.S.)
Are you 18 or older?
Yes
No
Car Available?
Yes
No
Desired Number of Hours Per Week
Availability
Please place a checkmark in every time period of each day you are available to work for us.
Sunday
Midnight - 8:00 am
8:00 am till Noon
Noon till 4:00pm
4:00pm - 8:00pm
8:00pm - Midnight
Live-In 24/7
Weekend Live-In
Monday
Midnight - 8:00 am
8:00 am till Noon
Noon till 4:00pm
4:00pm - 8:00pm
8:00pm - Midnight
Live-In 24/7
Tuesday
Midnight - 8:00 am
8:00 am till Noon
Noon till 4:00pm
4:00pm - 8:00pm
8:00pm - Midnight
Live-In 24/7
Wednesday
Midnight - 8:00 am
8:00 am till Noon
Noon till 4:00pm
4:00pm - 8:00pm
8:00pm - Midnight
Live-In 24/7
Thursday
Midnight - 8:00 am
8:00 am till Noon
Noon till 4:00pm
4:00pm - 8:00pm
8:00pm - Midnight
Live-In 24/7
Friday
Midnight - 8:00 am
8:00 am till Noon
Noon till 4:00pm
4:00pm - 8:00pm
8:00pm - Midnight
Live-In 24/7
Weekend Live-In
Saturday
Midnight - 8:00 am
8:00 am till Noon
Noon till 4:00pm
4:00pm - 8:00pm
8:00pm - Midnight
Live-In 24/7
Weekend Live-In
Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodation?
Yes
No
If No, please explain
When would you be available to begin work?
Type of employment desired
Full Time
Part Time
Hourly rate/salary desired?
EDUCATION
High School/Technical School
Location
College
Location
Other Training/Education
Location
To add additional education tap here
EMERGENCY CONTACT
Emergency Contact Name
Phone #
BACKGROUND AND CERTIFICATION
1. How did you hear of Companions & Homemakers?
2. Have you ever cared for an elderly or disabled person? Please explain
3. Have you ever worked for Companions & Homemakers, Inc. before?
Yes
no
If yes, when?
What branch?
Supervisor's Name
4. Have you ever been discharged by a prior employer?
Yes
no
If yes, please state name of employer and the reason
5. Have you ever been convicted of a crime in any state?
Yes
no
If you answered yes, please provide additional information below
6. Have you ever been subject to any decision imposing disciplinary action by a licensing agency in any state, the District of Columbia, a United States possession or territory or a foreign jurisdiction?
Yes
no
If you answered yes, please provide additional information below
CERTIFICATION
I CERTIFY THAT THE STATEMENTS MADE BY ME ON THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND ARE MADE IN GOOD FAITH. I UNDERSTAND THAT IF I KNOWINGLY MAKE ANY MISSTATEMENTS OF FACT, I AM SUBJECT TO DISQUALIFICATION AND DISMISSAL AND TO SUCH OTHER PENALTIES AS MAY BE PRESCRIBED BY LAW OR EMPLOYMENT AGENCY POLICY AND PROCEDURE.
*
Signature (type name)
*
Date
NOTICE TO APPLICANT CONCERNING ERASED CRIMINAL RECORDS
Under Connecticut law (1) You need not disclose the existence of any arrest, criminal charge or conviction that has been erased; (2) records subject to erasure for these purposes are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty, and a conviction for which a person received an absolute pardon; and (3) any person whose criminal records have been so erased shall be deemed never to have been arrested with respect to the erased records and may so swear under oath.
Companions & Homemakers, Inc. is an equal opportunity employer committed to hiring a diverse workforce.
I agree that this form may be electronically signed and agree that my typed signature is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.
Submit
About Us
Live-In Home Care
Hourly Home Care
Payment Options
News
FAQs
Employment
Benefits
Open Positions
Resources
Electronic Visit Verification (EVV)
Scholarships