HHHA-PreInterview

First Name

(Required)

Last Name

(Required)

Address

(Required)

City

(Required)

State

(Required)

Zip Code

(Required)

County of Residence

(Required)

Phone

(Required)

Email

(Required)

In what position are you interested?

C.N.A. Managerial Experienced Caregiver (non-certified) Clerical

(Required. Please choose one.)

Pay Expected

(Required)

How did you hear about us?

(Required. Please choose one.)

Employee Name

(Required)

If “Other”

(Required)

Requirements to Qualify

Are you 18 years old or older?

Yes No

(Required. Please choose one.)

You must be 18 years old to apply.

Do you have a valid driver’s license?

Yes No

(Required. Please choose one.)

If you do not have a valid driver’s license, please do not apply.

Do you own a reliable car?

Yes No

(Required. You must be able to transport yourself to/from work. You cannot be transported by someone else. Please choose one.)

You must be able to transport yourself to/from work. You cannot be transported by someone else. If you do not have a reliable car in order to transport yourself to/from work, please do not apply.

Do you have current auto insurance?

Yes No

(Required. Please choose one.)

If you do not have current auto insurance, please do not apply.

Insurance Company Name

(Required)

Do you have a smart phone

Yes No

(Required. A smart phone is used to sign in and out. Please choose one.)

A smart phone is required for multiple functions including clocking in/out. If you do not have a smart phone, please do not apply.

Have you been convicted of a felony?

Yes No

(Required. Please choose one.)

If you have been convicted of a felony, please do not apply.

Can you pass a drug screen?

Yes No

(Required. Please choose one.)

If you cannot pass a drug screen, please do not apply.

Can you lift 50lbs.?

Yes No

(Required. Please choose one.)

You must be able to lift 50lbs. If you cannot, please do not apply.

Are you available to work Monday-Friday?

Yes No

(Required. Please choose one.)

You must be available to work Monday through Friday. If not, please do not apply.

Are you available to work every other weekend including Saturday and Sunday?

Yes No

(Required. Please choose one.)

Normally, you must be available to work every other weekend. Circumstances preventing working every other weekend are handled on a case-by-case basis.

Experience & Certifications

Do you have previous experience as a caregiver?

Yes No

(Required. Please choose one.)

How many years of caregiving experience do you have?

(Required)

Please check the certifications that you currently have.

CNA First Aid CPR Other

Please list your other certifications

(Required)

Please check all the counties in which you are available to work.

(Required. Please choose all that apply.)

Other Counties

When would you be available to begin working with our company?

(Required)