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I am a caregiver/home companion, have checkable references and experience working with the elderly and infirmed. I would like to join the P&M Home Care Network of caregivers. I should be responsible, compassionate, emotionally stable, and cheerful. In addition, I should also be tactful, honest and discreet.

Please complete the following application. Print it out and mail it to us at the address indicated below indicated below. We will contact you shortly thereafter to arrange a personal interview at your convenience. 

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Personal Information*
First Name                           Last Name
  

Street Address


City                                        State                    Zip


Social Security Number


E-mail Address


Home Phone                          Cellular Phone
  

Are You Allergic To Any Pets?
Dogs  Cats   No Allergies  Other

Do You Have A Valid Drivers License?      Do You Own A Car?
Yes   No   Int'l License                Yes   No

If Yes Above - List State And License Number


What Languages Can You Speak?


Are You Legally Eligible To Work In This Country?
Yes   No

Have You Ever Been Convicted Of A Crime?
Yes   No   Explain

What Is Your Health Status?
Excellent Good Average Fair


Job Information*
Position Desired
Live In   Live Out   Weekend   I'm Flexible

When Are You Available To Start Work?
Immediately Other    

Least Amount Of Salary Acceptable?
Live In per day. Live Out per hour.

Neighborhood Of Choice? Check All That Apply.
Will go where assigned Manhattan Queens Brooklyn Staten Island Bronx Long Island

Experience*
Elderly Care Experience
Alzheimer's   Stroke   Cancer   Diabetes
Heart Attack   Parkinson's   Other



Education*
High School Name                                Year Graduated


High School Education Completed
9  10  11  12

College Name                                        Year Graduated


College Major                                        Years Completed


Other Training School Name               Course Of Study


List Any Certifications: CPR, First Aid, HHA, CNA etc.



Personal References*
Name - 1                                        Relationship  


Phone Number                              Length Of Time Known  


Name - 2                                        Relationship  


Phone Number                              Length Of Time Known  



Employment References*
Employer 1 - Name                      Employer 1 - Occupation


Was This Position Live In  Live Out

Employer 1 - Address
Street Address: City: State: Zip:

Employer 1 - Start Date       Employer 1 - End Date*
 
If Still Employed Leave Blank

Employer 1 - Job Duties
List All Duties:

Employer 1 - Salary
Salary: Reason For Leaving:

Employer 2 - Name                      Employer 2 - Occupation


Was This Position Live In  Live Out

Employer 2 - Address
Street Address: City: State: Zip:

Employer 2 - Start Date       Employer 2 - End Date*
 
If Still Employed Leave Blank

Employer 2 - Job Duties
List All Duties:

Employer 2 - Salary
Salary: Reason For Leaving:

Authorization To Release Information Disclaimers

*Authorization for Release of Information
I hereby authorize P&M Home Care Services Inc. (hereafter "the Agency), to perform investigations into my background, past behavior, to my character and general reputation. In addition, I further authorize investigations of the following: Consumer Reports:  I authorize the Agency to perform investigative consumer reports that may include credit reports, criminal history or arrest records, workers’ compensation histories, motor vehicle records, employment and unemployment records or other sources of information. Education:  I authorize schools, colleges and all scholastic institutions to release any and all information requested.  This includes transcripts, grades, attendance records, and any other information requested. Employment:  I authorize all former and current employers to release any and all information regarding my employment history.  This includes all information contained in my personnel file, salary history, condemnations, and all other pertinent information.  I further authorize my supervisors and other work associates to disclose their opinions and observations of my work habits, qualities, competency, and skills.  Furthermore, I authorize full disclosure of any and all drug and alcohol testing results. Authorization to Release:  I authorize custodians of the records of any agency, government agency,  or company as described above to release such information upon request of the Agency.  I understand that these investigations or inquiries can be performed prior to my referral or placement. Re-disclosure:  I understand that the information requested is for the use by the Agency and may be re-disclosed only as authorized by law.  I understand that I have the right to request from the Agency a written disclosure of the nature and scope of the investigation conducted that I authorized above. Indemnification:  I indemnify, release, and hold harmless the Agency, any agents of the Agency, or others reporting to or for the Agency, any investigators, all former employers, reporting agencies, and all those supplying references and character references, from any and all claims, defamation, demands, and/or liabilities arising out of, or related to, such investigations, disclosures, or admissions. Signature:  Copies and facsimile transmissions of this authorization that show my signature are as valid as the original release signed by me.

Please sign your name below:

please sign your name below:


Mail application to:
P&M Home Care Services Inc.
47-40 48th Street, Suite 1R, Woodside, NY 11377