Caregiver Application-Confidential

Please complete the following information and submit to us in order to be considered for a home caregiver position with a client of Angel Touch Home Care. This information will remain confidential and nothing will be divulged which is not authorized by you. Day position will be 12.00 per hour. Live-in position will start at $110.00 per day.

Own or Rent?

Have you ever been convicted of any felony or misdemeanor?


Some Care giving position require either a car or valid drivers license, including current and valid insurance coverage

Do you have an automobile?

Are you available for emergencies?

Are you available for 24 hr live-in position?

Are you a NJ Certified Home Health Aide?

or CNA?

If yes, what is your license number:

What do you like the most about working with seniors/elderly individuals?

What is your least desirable aspect of working with the elderly/seniors?

Employment History

May we contact your current employer to verify your employment history?

May we contact a previous employer to verify your employment history?

Current and Previous Landlords

Personal References

Are you eligible to work in the United States of America?

Certification and release: I certify the above information stated and indicated are true in fact
and no misrepresentation of myself has been made. I understand that any false information,
omissions or misrepresentation of facts will result in rejection of this application and/or
discharge at any time during employment. I authorize Angel Touch to verify any all information
contained within this application, but not limited to, criminal history and motor vehicle driving
records. I authorize all persons, school, companies, and law enforcement authorities to release
any information concerning my background and hereby release any said persons, schools,
companies and law enforcement authorities from any liability for any damage whatsoever for
issuing this information. I also understand that the use of illegal drugs is prohibited during
employment and that I am willing to submit to drug testing at any time to detect the use of
illegal drugs prior to or during employment.

Restrictive Covenant: I agree not to do business directly with any individual or business entity
that Angel Touch has introduced to me or by entering into employment with such individuals or
business without our written permission

all rights reserved

Angel Touch Home Care

Angel Touch Home Care