3973 8th Ave San Diego CA 92103 619-291-4663 phone, 619-923-1323 fax [email protected]

Application for Employment Love 2 Live is an equal opportunity employer. Love 2 Live makes employment decisions without regard to sex, race, color, religion, national origin, ancestry, age, disability, medical condition, gender identity, sexual orientation, marital status, veteran status, or any other legally protected characteristic. Name

Date

Street Address

City

State

ZIP

Home Phone

Mobile Phone

Email Address

Emergency Contact Name

Phone

Address

Relationship

Minimum Salary Requirement:

How did you hear about us?

Have you ever been convicted for a crime? (Exclude convictions for marijuana-related offenses for personal use more than two years old; convictions that have been sealed, expunged or legally eradicated, and misdemeanor convictions for which probation was completed and the case was dismissed).

yes

no

If yes, please briefly describe the nature of the crime(s), the date and place of conviction and the legal disposition of the case. This company will not deny employment to any applicant solely because the person has been convicted of a crime. The company however, may consider the nature, date and circumstances of the offense as well as whether the offense is relevant to the duties of the position applied for.

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**HOME CARE AIDE licensing requirement!** Have you completed your Home Care Aide registration through the Home Care Services Bureau? -

If YES, please provide your 10-digit HCA number:

-

If NO, please contact the Love 2 Live office to discuss the registration process. You can also visit the below website for more information or to begin the registration process. http://www.ccld.ca.gov/pg3654.htm

Transportation

(Many caregiver positions require the caregiver to transport a client) Do you have dependable transportation?

yes

no

Are you able to safely transport clients in your vehicle (Shopping, Doctor appointments, etc.)

yes

Education High school

City/State

Major

College

City/State

Major

Other

City/State

Major

Certificates/Training

Experience Discuss any training or experience working with the elderly.

What would you like most about working with the elderly?

What would you like least about working with the elderly?

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no

Availability Tell us about your availability. Be very specific. What days, hours? Any scheduling challenges we should know about?

Would you ever consider doing a 24 Hour shift for a couple of days? Yes No How many hours do you need to work per week?

If we had an emergency (someone needing extra care, someone not showing up for work), could we call you at the last minute? Yes No

What days or hours can you NEVER work?

Please check the day(s) you are available for, specify times, and circle all other options. Monday From to 24 Hour Occasional Fill-in Overnights Tuesday From to 24 Hour Occasional Fill-in Overnights Wednesday From to 24 Hour Occasional Fill-in Overnights Thursday From to 24 Hour Occasional Fill-in Overnights Friday From to 24 Hour Occasional Fill-in Overnights Saturday From to 24 Hour Occasional Fill-in Overnights

Work Area How far are you willing to drive to for a shift? Again, be very specific, tell us how many miles, what parts of town, or how much driving time. Remember that the more flexible you are with areas you will work, the better schedule we will be able to give you. We have clients all over the city!

Sunday From to 24 Hour Occasional Fill-in Overnights Please check ALL areas you are willing to work in. East La Mesa El Cajon Central Clairemont North Park Kearney Mesa SDSU North Inland Escondido Rancho Bernardo Coastal Point Loma La Jolla Encinitas Carlsbad

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Employment History

Please go back at least five years and tell us about your work history. Use reverse side of sheet if additional space is required.

Company

From

Job title

Reason left

To

Duties

Supervisor

May we contact this employer?

Phone

yes

no

Starting Salary:

Company

From

Job title

Reason left

Ending Salary: To

Duties

Supervisor

May we contact this employer?

Phone

yes

no

Starting Salary:

Company

From

Job title

Reason left

Ending Salary: To

Duties

Supervisor

May we contact this employer?

Phone

yes

no

Starting Salary:

**Please attach your resume, if available**

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Ending Salary:

Professional References Name

Relationship/ Company

Years Known

Phone #

Name

Relationship/Company

Years Known

Phone #

Name

Relationship/Company

Years Known

Phone #

Name

Relationship/Company

Years Known

Phone #

Name

Relationship/Company

Years Known

Phone #

Name

Relationship

Relationship/Years Known

Phone #

Name

Relationship

Relationship/Years Known

Phone #

Name

Relationship

Relationship/Years Known

Phone #

Name

Relationship

Relationship/Years Known

Phone #

Name

Relationship

Relationship/Years Known

Phone #

Personal References

CERTIFICATION AND RELEASE: I certify that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for Love 2 Live Care Services to hire me. If I am hired, I understand that either Love 2 Live Care Services or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of Love 2 Live Care Services has the authority to make any assurance to the contrary. Signature

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Date