Name
Street Address
City
State
Zip Code
Phone Type
Phone Number
E-mail
Have you lived outside of Michigan in the last 10 years? No Yes
Are you 18 years or older? No Yes
Have you ever been convicted of any crime or have felony charges pending?
No Yes
If yes, what was the conviction for and when?
Are you CNA certified? No Yes
Have you ever worked for or applied with Affordable HomeCare before? No Yes
How many years of experience do you have caregiving? None 1-2 3-5 6 +
Are you able to provide at least 5 references directly linked to caregiving? No Yes How many?
Do you have a reliable source of transportation? No Yes
Would you have a problem with Affordable HomeCare giving you a drug test? No Yes
What position are you intrested in? Live-in Hourly Housekeeping
How did you hear of Affordable HomeCare Other:
Please tell us a little about you
and why you would
like to work for
Affordable HomeCare.
 


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updated 6/30/08