EMPLOYMENT APPLICATION
THE COMPANY THAT CARES ABOUT ITS CAREGIVERS
AN EQUAL OPPORTUNITY EMPLOYER
9/2/2020
Today’s Date: ___________________
_________________________________________________________________________________________________
Circle One: RN LPN How Were You Referred To Us? E-Mail
CNA HHA PCA HM LI Indeed Hopkins.yakira@gmail.com
X
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(Print) Name, Last First Middle Home Phone
5187041262
Cell Phone & Carrier
Jackson
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Yakira M.J.
Street Address City County Zip Code
12307
Social Security No.
Schenectady 203785841
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1005 Stanley street
X X
Yes □ Are You Yes □ Professional Check all that apply. Available for:
Uniforms: No □ Over 18? No □ Liability Ins. Yes □ NoX□ Home Care X□ Staffing □ Live In □
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Worked for Temporary Service Before? Yes □ No X□
Name: Address: Worked From: To:
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Worked/Applied to Attentive Care before? Yes □ No □ X Professional or Driver’s
03/02/20
If Yes: From: To: License No. State: NY Expiration Date: 22
524240276
_________________________________________________________________________________________________
X
CPR Certified: Yes □ No □ Expiration date: _____________ 2021
Speak Foreign Language: Yes X□ No □
ACLS Certified: Yes □ No □X Expiration date: ______________ Spanish , Patios
If Yes, what? __________________________
Ever denied a bond? (Give details) Yes □ No □ X Allergies: Yes □ No X□
What? _________________________________
05/2020
Ever convicted of a crime? (Give details) Yes □ No X□ Date of Last Physical Exam: _______________
Legally authorized to work in US? YesX□ No □
If YES, details from Above:
________________________________________________________________________________
_________________________________________________________________________________________________
X PLEASE CHECK PAST EXPERIENCE
X
□ Private Duty Home □ Rehabilitation Unit □ Catheter Care X□ Prepare Meals
□ Private Duty Hospital □ OB/GYN □ Urine Tests □ Bed Baths
□ Staffing Hospital □ ICU/CCU Unit X□ Blood Pressure X□ Grooming Patient
□ Staffing Nursing Home □ PCU Unit □ Pulse/Respiration/Temp. X□ Assist with Toileting
□ Geriatric Unit □ Burn Unit □ Nasal Feed X□ Assist with Exercise
X
□ Pediatric Unit □ Respiratory Unit □ Administer Oxygen □ Keep simple Records
X□ Respirator/Ventilator X
□ Psychiatric Unit □ Orthopedic Unit □ Shopping
□ OR/Post Operative □ Emergency Room □ Braces/Splints X□ Light Housekeeping
X
□ Oncology/Hospice □ Venipuncture X□ Hoyer Lift □ Patient Laundry
□ Medical/Surgical Unit □ Colostomy Care □ Special Equipment _____ X □ Simple Dressing Change
Describe past healthcare experience/any specialties: ______________________________________________________
I was a DSP for 3 years
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Please answer in brief paragraph – Check when you can work:
why did you choose this particular type of work?
Days Eve Night L/I
Sat
Sun X
Mon X X
Tues X X
Schenectady, Albany, Troy, Amsterdam Wed X X
Thurs X X
Locations available to work: ______________________________________
Anytime
What is the best time to reach you? _________________________________ Fri X X
Can you be available for last minute calls to work? Yes □ No □ X
DO NOT WRITE BELOW THIS LINE – GO ON TO REVERSE SIDE
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Notes:
C: Attentive 07/99 #86A
r: 09/14,2/15,12/17
PAST EMPLOYMENT
________________________________________________________________________________________________
Dates Employed Supervisor
From To Name and Address Position & Telephone No. Reason for Leaving
_________________________________________________________________________________________________
ATTACHED RESUME
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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EDUCATION
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Schools: Dates
High School: From: To: Courses Taken Diploma/Degree
Address:
Schenectady High school 2014-2018 Diploma
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Nursing School:
Address:
_________________________________________________________________________________________________
College or Business:
Address:
_________________________________________________________________________________________________
Other:
_________________________________________________________________________________________________
PROFESSIONAL REFERENCES
_________________________________________________________________________________________________
List two Professional References (can be MD, nurse, lawyer, clergy, etc.)
Name: Address Position Telephone
_________________________________________________________________________________________________
Eliana Harris
5188196550
_________________________________________________________________________________________________
Nati abdad
_________________________________________________________________________________________________ 5187031116
Please refer at least 2 friends or relative to work for Attentive Care:
Essence Day Ciyan Dominique
Name: ______________________________________ Name: ______________________________________
Address: _____________________________________ Address: _____________________________________
5183849172
Phone Number: _______________________________ Phone Number: ________________________________
5185423673
Job: _________________________________________ Job: _________________________________________
I hereby authorize ATTENTIVE CARE to request and also authorize each former employer and person given as a
reference to answer all questions that may be asked concerning myself or my work habits.
I agree in consideration of your employing me, that I will not seek or accept employment either directly or
indirectly from any client of ATTENTIVE CARE to whom I have been assigned, for a period of at least three
months after the last day of that assignment. In the event I violate the terms of the Agreement, I agree to pay
ATTENTIVE CARE upon demand, the sum of $2,500 as a conversion fee. Any false statement or falsification of
this record herein may be grounds for termination of employment.
9/2/2020
Date: _________________ Applicant’s Signature: ______________________________________________
An Equal Opportunity Employer
C: Attentive 07/99 #86A
r: 09/14,2/15,12/17
