CAS Services is an independently owned and operated Home Instead® franchise 442 Pleasant St, Blue Hill, ME 04614 207-404-2529.

INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.

• Please read "Applicant Note” below.
• Complete all pages off this application.
• Print clearly. Incomplete or illegible applications may not be accepted.
• If more space is needed to complete any question, use comments section on the back.
• Application will be valid for 60 days.

Applicant Note: This application form is intended for use in evaluating your qualifications for employment with us , an independently owned and operated Home Instead franchise. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law.

* Are you 19 years of age or older?

Yes   No

* Are you able to lift 25 pounds?

Yes   No

* Do you have reliable transportation?

Yes   No

* Have you ever submitted an application here before?

Yes   No

* You have been given a copy of the job description for the position for which you have applied. Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation?

Yes   No

Please check the highest grade level completed:

Grade School:

6   7   8

High School:

9   10   11   12

College:

13   14   15   16   16+

	Name	City, State	Major Subjects	# Yrs Attended	Graduate?
High School	*	*		*	* Yes No
Vocational/Technical					Yes No
College/University					Yes No

Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.

Company Name	City and State	Company Phone
Dates Employed	Job Title	Supervisor Name
From: To:
Duties
What did you like most about this position?	Reason for Leaving

Company Name	City and State	Company Phone
Dates Employed	Job Title	Supervisor Name
From: To:
Duties
What did you like most about this position?	Reason for Leaving

* Desired Compensation per___?

* HourWeekMonth

* Describe any work history or training you've completed related to senior care and service:

* Describe any extracurricular activities/honors/awards.

* List any memberships in professional or job relevant organizations:

Please complete all four references (two professional/two personal). Your application will not be considered unless two references are provided. Since we will contact these references, please notify them in advance. .

Professional References

Full Name	Phone Number	Email	Relationship	Number of Years Known
*	*	*	*	*
*	*	*	*	*

Personal References

Full Name	Phone Number	Email	Relationship	Number of Years Known
*	*	*	*	*
*	*	*	*	*

I certify that I have read and understand the applicant note above and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application process may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I also understand that the use of illegal drugs is prohibited when carrying out my job responsibilities. I am willing to submit to drug screening to detect the use of illegal drugs prior to and during employment, as allowed under applicable law.

I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT OF EMPLOYMENT.

By typing your name below you are electronically signing this document.

* Signature (type full name):
* Date:

Please indicate those tasks in which you have experience. For the areas that you do not have experience, please note if you are willing to learn.

Tasks	Experience Yes/No	Willing to Learn
Companionship/Conversation	* Yes   No	Willing to Learn
Meal Preparation (meals/snacks)	* Yes   No	Willing to Learn
Housekeeping (dust, vacuum, laundry)	* Yes   No	Willing to Learn
Bathing/showering Assistance	* Yes   No	Willing to Learn
Dressing Assistance	* Yes   No	Willing to Learn
Showering Assistance	* Yes   No	Willing to Learn
Medication Reminders	* Yes   No	Willing to Learn
Hospice Care	* Yes   No	Willing to Learn
Stroke Care	* Yes   No	Willing to Learn
Dementia Care	* Yes   No	Willing to Learn
Incidental Transportation & Errands	* Yes   No	Willing to Learn
Incontinence Care	* Yes   No	Willing to Learn
Personal Care Assistance (Female)	* Yes   No	Willing to Learn
Personal Care Assistance (Male)	* Yes   No	Willing to Learn
Alzheimer’s or Dementia Care	* Yes   No	Willing to Learn
Diabetes Care	* Yes   No	Willing to Learn
Hearing Impairment	* Yes   No	Willing to Learn
Transferring Assistance (Example: helping a person from chair to standing position)	* Yes   No	Willing to Learn
Ambulation Assistance (Example: Ensure a person’s stability and safety when moving)	* Yes   No	Willing to Learn
Mechanical Lift (Hoyer Lift)	* Yes   No	Willing to Learn

* How many years of experience do you have as a caregiver?