Today's Date: *

First Name *

Last Name *

Phone *

Email *

Are you authorized to work in the U.S.? *

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How did you hear about Senior helpers? *

Indeed
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How would you rate your conversational English skills? (1 = Poor, 5 = Excellent) *

5 = excellent

4 = good

3 = fair/moderate

2 = needs improvement

1 = poor

Are you currently employed? *

Employed
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Available start date: *

Which days can you work? *

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Are you available to work weekends? *

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Sometimes
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Are you available to work nights? *

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Sometimes
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Which area/s would you like to work in? *

Bryan/College Station + surrounding areas
Conroe/The Woodlands/Spring + surrounding areas
Lake Conroe/Willis/Huntsville + surrounding areas
Hilltop Lakes/Crockett/Palestine + surrounding areas
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Do you have any of the following certifications?

Certified Nursing Assistant (CNA)
Home Health Aide (HHA) Certification
CPR Certification
Basic Life Support (BLS)
First Aid Certified
Other
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How many years of caregiving experience do you have? *

Just starting - less than 1 year

1 - 2 years

2 - 3 years

3 - 5 years

5+ years

Do you have a car? *

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Do you currently hold a valid driver's license? *

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No
I'm in the process of acquiring one
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Do you currently have car insurance? *

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No
I'm in the process of acquiring one
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Have you had any moving violations or accidents during the past three years? *

0
1
2
3
4+
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Are you able to pass a background check? *

Yes

No

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Are you able to pass a drug test? *

Yes

No

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