Pre-Hire Caregiver Application - Caregiver Profile Applicant Name* First Last Position Applied For*Phone #1*Phone #2*Email* City*Cross Streets*Areas available for work*Work AvailabilityWork Availability*Day of the weekHours AvailableNotes How much noticed needed before schedule?*1 Hour4 Hour8 Hour24 Hour48 Hour72 HourDo you have an insured vehicle or reliable transportation?*YesNoAre you available after hours?*YesNoAre you a smoker?*YesNoCan you work with a client that smokes?*YesNoCan you work with clients that has pets?*YesYesAre you able to lift?*YesNoDo you have experience with a Hoyer lift or gait belt for transfers?*YesNoI have reviewed the job description for the position which I am applying for and certify that I meet the minimum requirements. Additionally, I have reviewed the examples of immediate disqualifiers for consideration of employment and don't expect those disqualifiers or similar to affect my ability to be considered for employment.