Employment application

Applicant information

Full legal name (required)

Preferred name (optional)

Street address / apartment (required)

City (required)

State (required)

ZIP code (required)5 digits, like 43215

Primary phone (required)US number, like (614) 555-0123

Alternate phone (optional)

Email address (required)

Preferred contact method (required)

PhoneTextEmail

Position and employment preferences

Position applying for (optional)

Date available to begin (required)

Desired pay (optional)

Preferred work area(s) (optional)

Employment type. Choose all that apply. (required)

Full-timePart-timePRN / As needed

Weekly availability

Tick every time of day you can work, for each day of the week.

Shift restrictions or additional availability (optional)0 of 300 characters used

Education and training

All optional. Fill in what applies to you.

High school / GED

School / institution

Degree, diploma or training completed

College / university

School / institution

Degree, diploma or training completed

Vocational / other training

School / institution

Degree, diploma or training completed

Licenses and certifications

License / certification and number (if applicable) (optional)

Expiration date (optional)

Other licenses, credentials, or specialized training (optional)0 of 300 characters used

Caregiving experience and skills

Years of related care experience (optional)

Other relevant skills (optional)0 of 300 characters used

Describe your relevant caregiving experience (optional)0 of 2000 characters used

Employment history

List your most recent employers, starting with the current or most recent position. Leave this blank if it does not apply.

Employer 1

Employer / organization

Phone

Job title

Supervisor name

Dates employed (from - to)

Reason for leaving

Main responsibilities 0 of 1000 characters used

May we contact this employer?

YesNo

Professional references

Provide two professional references (preferably supervisors or coworkers). For each, a name and a phone number or email is required.

Reference 1

Name (required)

Professional relationship (optional)

Phone

Email

Reference 2

Name (required)

Professional relationship (optional)

Phone

Email

Job-related questions

Are you legally authorized to work in the United States? (required)

YesNo

Can you perform the essential functions of the job, with or without reasonable accommodation? (required)

YesNo

Do you have reliable transportation for shifts or travel required by the position? (required)

YesNo

Additional information you would like us to consider (optional)0 of 2000 characters used

Applicant acknowledgment and signature

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that material misrepresentation or omission may result in refusal to hire or termination. I authorize COOLO Care to verify the job-related information provided, consistent with applicable law. I understand this application does not constitute an employment contract and, if hired, employment is at will to the extent permitted by law. Any required background-screening authorization will be separate.

I agree to the statement above. (required)

Applicant signature: type your full legal name (required)

Date (required)

Draw your signature (optional, your typed name above is your signature)Use your finger, a stylus or a mouse in the box below. Keyboard users can skip this.

Join ourcare team.

Applicant information

Position and employment preferences

Weekly availability

Education and training

Licenses and certifications

Caregiving experience and skills

Employment history

Professional references

Job-related questions

Applicant acknowledgment and signature

Join our
care team.