Every Day Matters – Making Life Easier

First name *

Middle name

Last name *

Email *

Address *

City *

State *

Zip code *

County *

Cell phone *

Home phone (land line)

Leave blank if no home phone.

Do you agree to a criminal background check *

Yes

No

State law requires a criminal background check for this position.

Date of birth *

Your Date of Birth is required to run the background check.

Social Security Number *

Do you agree to a drug screen? It will be conducted as part of your interview? *

Yes

No

State law requires a drug screen for this position.

Do you have a reliable car you can keep with you on the job? *

Yes

No

Caregivers may need to drive clients for errands. You will be reimbursed for any mileage driven on the job.

Do you have a valid drivers license? You must be able to present this at the interview. *

Yes

No

Do you have auto liability insurance with your name on the card? You must be able to present this at the time of your interview. *

Yes

No

About how many hours a week do you want to work? *

What else would you like to tell us?

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