Apply Now! | HomeAttendantCare.com

Please submit the following forms (in person, to Home Attendant Care, 1316 King Street, Bellingham, WA 98229, by email, or upload them in the digital application):

For more information, please contact:
Sharon Smith, Human Resources Manager
ssmith@homeattendantcare.com
Home Attendant Care, 1316 King Street, Bellingham, WA 98229
Phone: 360-734-3849

Home Attendant Care, Inc. Employment Application

Name *

Date *

Phone *

Email *

Address *

Apt, suite, etc.

Country

City

State

Zip code

Have you ever applied to or worked for H.A.C. before? *

Yes

If yes, when?

Are you eligible for legal employment in the US? *

Yes

Date available to begin work: *

Do you have any criminal or motor vehicle convictions? *

Yes

Times available: Please check all shifts you can work *

Hourly

12 hour days

24 hour

NOC

Bath Assist

Yes

Bed Bound Care

Yes

Catheter Care

Yes

Dementia Care

Yes

Hospice Care

Yes

Incontinent Care

Yes

Mechanical Lift

Yes

Full Pivot Transfer

Yes

NAR or NAC

Yes

Fundamentals

Yes

Aids Training / Certificate

Yes

Do you have a valid driver’s license?

Yes

Do you have a vehicle to drive on the job?

Yes

Do you have automobile insurance?

Yes

Education & Experience

Education / Certifications:

Degrees/Certificates/Specialized Training:

Education / Certifications:

Other Degrees/Certificates/Specialized Training:

1. Employer:

Phone Number:

City/State:

Your Position:

Supervisor’s name:

Dates Employed:

Salary:

Reason for Leaving:

If still employed, may we contact your current employer?

Yes

2. Employer:

Phone Number:

City/State:

Your Position:

Supervisor’s name:

Dates Employed:

Salary:

Reason for Leaving:

If still employed, may we contact your current employer?

Yes

3. Employer:

Phone Number:

City/State:

Your Position:

Supervisor’s name:

Dates Employed:

Salary:

Reason for Leaving:

If still employed, may we contact your current employer?

Yes

1. Name:

Phone Number:

City/State:

Years Known:

2. Name:

Phone Number:

City/State:

Years Known:

Authorization

Please initial to verify that you have reviewed the attached job description: *

Is there any reason that would prevent you from effectively and safely performing this job? *

Yes

If Yes, please give a brief explanation

Authorization

I authorize investigation of all statements contained in the application and understand that employment is contingent upon a Washington State Patrol criminal background check listing no convictions which would reflect upon your suitability for unsupervised work with vulnerable adults including but not limited to those listed on the DSHS secretaries list of crimes and negative actions. I understand that as a part of Home Attendant Care, Inc’s hiring procedure Washington State Child Protective Services, Adult Protective Services, Washington State Patrol or other agencies as allowed by law will be checked for relevant information that may be used in Home Attendant Care, Inc’s hiring decision. I also understand that Home Attendant Care, Inc. may make periodic reviews of the aforementioned agency checks for relevant information for continuing employment. I also understand that my signature below acts as my authorization for each of these agencies to release information to Home Attendant Care, Inc. I hereby understand and agree that any offer of employment with this organization is of an “at will” nature, which means that the employee may resign at any time and the employer may discharge employee at any time with or without cause. Further, I understand that false or misleading information or omission of facts called for in the application or interview(s) is cause for dismissal. Home Attendant Care, Inc. is an equal opportunity employer.

Signature

Reset Signature

Print Name *

Date *

Completed Background Check Authorization

Upload to this form, or submit in person

Completed Employment References

Upload to this form, or submit in person

Please attach a resume (optional)

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Caregiver Position Description