Employment Application

EMPLOYMENT APPLICATION - AT HOME SERVICES, INC.

514 N "H" Street, Ste.B, Lompoc, CA 93436

tel: 805 736-8249 fax. 805 736-8258

Email: info@at-homeservices.com

DATE:

Last Name:

First Name and Middle Initial:

Social Security Number (last 4 digits):

Street Address and Apt. Number:

City:

State:

Zip Code:

Home Telephone/Cell:

email Address:

Have you earned a GED or a high school diploma?:

Position applying for:

Licenses, Registrations, and Certificates
	Number		Expiration
	Number		Expiration


May we contact past employers and references you have listed?	Yes No
What days and hours are you available for work?
DAY	START	FINISH
Monday:	Start	Finish
Tuesday:	Start	Finish
Wednesday:	Start	Finish
Thursday:	Start	Finish
Friday:	Start	Finish
Saturday:	Start	Finish
Sunday:	Start	Finish

Do you have daily access to a reliable car you would be willing to use for local travel?

Yes

Do you have any physical conditions that limit your ability to do care or housework? Please describe below:

Can you lift and/or transfer a client?

Yes

**Services you desire to perform:**
Personal Care	Household
Shower: sitting, standing	Meal preparation
Bath: Tub	Shopping
Bath: Bed	Transportation to appointments, shopping
Shaving	Dishwashing
Grooming: hair, nails trim	Vacuuming
Oral care	Dusting
Dressing	Heavier cleaning: carpets, windows, refrigerators
Lifting to stand, walk	Bed making
Transfer to chair, use commode	Change bedding
Care for incontinence	Launder clothing
Colostomy	Outdoor, yard
Respiratory care: oxygen, inhalers	Reading aloud
Exercise, range of motion	Correspondence
Monitor medications	Visiting (Socialization)
Take vital signs	Other

What wage do you expect to be paid for these services?: $ /hr

Have you completed this form yourself?

Yes

The information provided here is true and complete to the best of my knowledge. Initial if yes: