Apply for a job

The information you provide here may be shared with potential employers. Terms of employment are made strictly between the two parties involved. Please complete this form so we can learn more about you. When you have filled it out, use the Submit button at the end to send us your information.
First Name:
Last Name:
Street Address:
City:
State/Province:
Zip/Postal Code:
Country:
When is a good time to contact you?	AM PM
At what telephone number?	Area:
Do you use TTY/TTD service?	Yes No
Email:
Did you contact us because you were interested in working:(Check all that apply)	For an agency? For an individual?
Where did you hear about this job opportunity?
	Name of TV station, newspaper or website?
	Other:
Are you looking for:	Full-time employment? Part-time employment? No Preference
Are you 18 years old or over?:	Yes No
Do you prefer working with:(Check all that apply)	Adults Elders Children
Do you have any allergies?:(Check all that apply)	No allergies AnimalsIf Yes,which ones Cigarette, Cigar or Pipe Smoke Other
Are you available to work:	Days Evenings Early Mornings Overnights Weekends
Are you willing to work back-up or as needed?	Yes No
When can you start?	Immediately Within two weeks More than two weeks from now
Do you prefer working for an agency where you will likely work with small groups of people?	Yes No No Preference
Do you prefer working directly with one person in their own home or in a community setting?	Yes No No Preference
Are you interested in living in an individual's home?	Yes No No Preference
Are you interested in providing support services to an individual in your own home?	Yes No
Do you have preferences about the kind of work you wish to do?	Yes Please describe: No
State(s) you wish to work in	CT MA ME NH NJ RI VT
How many miles would you be willing to travel to your job?	Miles
Do you have a valid driver's license?	Yes No
Do you have a car?	Yes No
Describe your work experience:
Describe any special skills, training or valid certification that you have such as CPR, First Aid or certification in medication administration:
Are you a certified Home Health aide in the state of New Jersey?	Yes No
What is the highest level of education you have achieved?
Are you legally able to work in the US?	Yes No
Are you fluent in any of the following languages? (Check all that apply)	English Creole French Khmer Laotian Polish Portuguese Russian Spanish Vietnamese American Sign Language
Other fluent language

Please be courteous to potential employers. If you are contacted for a job interview, please be polite whether or not you are sure the position is the one you want. If you have arranged to meet for an interview, it is important to show up on time. If you cannot make the interview FOR ANY REASON, please contact the employer in advance since they have set aside the time to meet with you. Letting the employer know that you cannot make the interview shows that you are responsible.

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