Thank you for applying to

Inter-Coastal Home Care

Tell us about Yourself

Full Name *

Phone Number *

Email *

Street Address *

Date of birth *

Work Authorization

City & State *

ZIP code *

Are you 18 years of age or older? *

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Do you have a birth certificate or other proof of age? *

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Can you, at the time of orientation, submit proof of your legal right to work in the U.S.? *

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Are you a U.S. citizen or authorized to work in the U.S. on an unrestricted basis? *

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Let's Talk About the Role

Position(s) you are applying *

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Date available to start *

What is your availability? Please be specific as possible *

Are you available any day, any hour? *

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Are you available to work on holidays? *

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Are you willing to travel to and from clients' homes? *

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Are you presently employed? *

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Transportation

Do you own a car with current insurance? *

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Do you have a valid driver's license? *

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Do you have dependable transportation to and from work? *

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Background and Skills

Have you previously worked for Inter-Coastal Home Care? *

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Have you worked as a Homemaker or Companion? *

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Do you speak, read, or write in any language other than English? *

Do you have a criminal history? *

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Please List any additional education, training, certificates, or special skills

References

Reference 1 *

Reference 2 *

Reference 3

Work Experience

Previous Employer 1 *

Previous Employer 2 *

Previous Employer 3

How did you find us?

How did you hear about us? *

If referred, please provide their name

Resume (If any)

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