Home-care Worker

Application for Employment

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Work Availability

Date Available To Start Work?

Are you willing to work overtime?

Yes No

Are you willing to work weekends?

Yes No

Are you willing to work as a substitute?

Yes No

Are you able to lift (25) lbs?

Yes No

Are you willing to work as a Live-in?

Yes No

List any physical limitations that you may have:

Please indicate your availability:

Time	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
6:00 am
7:00 am
8:00 am
9:00 am
10:00 am
11:00 am
12 Noon
1:00 pm
2:00 pm
3:00 pm
4:00 pm
5:00 pm
6:00 pm
7:00 pm
8:00 pm
9:00 pm
10:00 pm
11:00 pm
12 Midnight
1:00 am
2:00 am
3:00 am
4:00 am
5:00 am