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 Availability Work 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?* Yes No Are you available after hours?* Yes No Are you a smoker?* Yes No Can you work with a client that smokes?* Yes No Can you work with clients that has pets?* Yes Yes Are you able to lift?* Yes No Do you have experience with a Hoyer lift or gait belt for transfers?* Yes No I 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.