Caregiver Job Application | Join Home Guardian Angels

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General Information

First Name(Required)

Middle Name

Last Name(Required)

Date Of Birth(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County(Required)

Area Code(Required)

Phone Number(Required)

*Without Area Code

Cell Area Code

Cell Phone Number

*Without Area Code

Email(Required)

Social Security Number(Required)

Upload Social Security Card Image

Max. file size: 1 GB.

Upload ID or Passport Image

Max. file size: 1 GB.

Alternate Information

The forms within the New Hire Packet may require your general information in different formats.

Full Name(Required)

Last Name, First Name, and Middle Initial(Required)

First Name and Middle Initial(Required)

Middle Initial

Different Name

Yes

Different Name - If Yes

Full Street Address(Required)

*Include Apt #

Address City, State, and ZIP Code(Required)

Mailing Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Full Phone Number(Required)

Filing Status(Required)

Single or Married Filing Separately

Married Filing Jointly or Surviving Spouse

Head Of Household

Employment Details

Other Position

Date Available

MM slash DD slash YYYY

Please Specify Days and Hours

Rate of Pay Expected per hour

If currently employed, may we contact your employer?

Yes

What motivates you to seek employment with our company?

Referred To Us By

Are you legally authorized to work in the United States?

Yes

Are you available to work overtime if required?

Yes

Have you applied with this company before?

Yes

Have you been employed at this company before?

Yes

When?

What Location?

Do you have any friends or family employed at this location?

Yes

If considered for hiring, will you agree to provide a criminal background check?

Yes

If considered for hiring, will you agree to provide a drivers abstract?

Yes

Educational Background

List previous three (3) educational institutions attended, beginning with the most recent.

School 1

School 1 - City & State

Graduated School 1?

Yes

School 1 - Degree

School 2

School 2 - City & State

Graduated School 2?

Yes

School 2 - Degree

School 3

School 3 - City & State

Graduated School 3?

Yes

School 3 - Degree

Credentials

What Nursing or relevant designations, licenses or registrations if any, do you possess?

Credentials 1 - Type

Credentials 1 - Date of Most Recent Registration

Credentials 1 - Valid in State/Province?

Yes

Credentials 2 - Type

Credentials 2 - Date Registration

Credentials Valid 2

Yes

CPR

Yes

CPR - Certified

First Aid

Yes

First Aid - Certified

Employment Background

Past Employer 1

Past Employer Name 1

Past Employer Area Code 1

Past Employer Phone Number 1

Past Employer Job Title 1

Past Employer From Date 1

Past Employer To Date 1

Past Employer Full Address 1

Past Employer Supervisor, Title, and Phone Number 1

Past Employer Reason For Leaving 1

Contact Reference 1

Yes

Later

Past Employer 1 Type of Work 1

Past Employer 1 Type of Work 2

Past Employer 1 Type of Work 3

Past Employer 1 Type of Work 4

Past Employer 1 Type of Work 5

Past Employer 2

Past Employer Name 2

Past Employer Area Code 2

Past Employer Phone Number 2

Past Employer Job Title 2

Past Employer From Date 2

Past Employer To Date 2

Past Employer Full Address 2

Past Employer Supervisor, Title, and Phone Number 2

Past Employer Reason For Leaving 2

Contact Reference 2

Yes

Later

Past Employer 2 Type of Work 1

Past Employer 2 Type of Work 2

Past Employer 2 Type of Work 3

Past Employer 2 Type of Work 4

Past Employer 2 Type of Work 5

Emergency Contact

Emergency Contact Name 1

Emergency Contact Area Code 1

Emergency Contact Phone Number 1

Emergency Contact Years Acquainted 1

Emergency Contact Relationship 1

Emergency Contact Name 2

Emergency Contact Area Code 2

Emergency Contact Phone Number 2

Emergency Contact Years Aquainted 2

Emergency Contact Relationship 2

Emergency Contact Name 3

Emergency Contact Area Code 3

Emergency Contact Phone Number 3

Emergency Contact Years Aquainted 3

Emergency Contact Relationship 3

Home Care Aide Registration or Renewal

Application Type

Initial Application

Renewal Application

Per ID/HCA ID (if applicable)

ID Document Type

Valid California Driver’s License

Valid California Identification Card issued by the Department of Motor Vehicles

Valid Permanent Resident Card

For a person living in a state other than California, a Valid Numbered Photo Identification Card issued by a state agency other than California

Issuing State

Document Number

Document Expiration Date

Disclosure of Personal Information and Opt-Out Information

I wish to opt-out. I do not want my contact information provided to labor organizations.

Criminal Record Statement

Have you ever been convicted of a crime in California ?

Yes

Have you ever been convicted of a crime from another state, federal court, military or jurisdiction outside of U.S.?

Yes

Do you possess a valid California Driver's License?

Yes

DMV License Number

What was the offense?

In which state and city did you commit the offense?

When did this occur?

Tell us what happened.

California Withholding Allowance Certificate

Number of Regular Withholding Allowances

Number of allowances from the Estimated Deductions

Total Number of Allowances you are claiming

CA Additional Withheld

Exemption

I claim exemption from withholding for 2024, and I certify I meet both of the conditions for exemption.

Not Subject to Witholding

I certify under penalty of perjury that I am not subject to California withholding.

Direct Deposit

Deposit Account 1

Checking

Savings

Direct Deposit Type 1

New

Change

Use Previous Account Information in File

I wish to have:

100%

Fixed Amount

Remaining Balance

Fixed Amount to Deposit

DD Bank Name 1

DD Bank Phone Number 1

DD Bank Routing Number 1

DD Bank Account Number 1

Deposit Account 2

Checking

Savings

DD Type 2

New

Change

Cancel

DD Amount 2

100%

Fixed

Remaining

DD Amount - Fixed Amount 2

DD Bank Name 2

DD Bank Phone Number 2

DD Bank Routing Number 2

DD Bank Account Number 2

Upload A Voided Check

Max. file size: 1 GB.

Signature

Signature(Required)

New Hire Application

General Information

Alternate Information

Employment Details

Educational Background

Credentials

Employment Background

Emergency Contact

Home Care Aide Registration or Renewal

Criminal Record Statement

California Withholding Allowance Certificate

Direct Deposit

Signature

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