For Companions

Job Application

Please complete this application as completely and accurately as possible.

Download this Form

Personal Information

First Name: Middle Name:

Optional

Last Name: Address 1: Address 2:

Optional

City: State:

Zip Code:

Home Phone Number:

Cell Phone Number:

Optional

Email: Nursing License Number or CNA Certification Number:

Optional

Are you over the age of 18?

Are you a U.S. citizen?

If no, do you have the legal right and neccessary documents to work in the U.S.? (Identity and employment eligibility will be verified as required by law.)

Have you lived in Illinois 2 years or more?

Employment Information

Position Desired:

Optional

Part Time
Full Time

Shift Preference:

Optional

Salary Request:

Optional

Date available for Work:

Do you possess a valid driver’s license?

Driver's License Number:

Optional

Do you have your own transportation?

Have you applied here before?

If so, when:

How were you referred to us?

Qualifications & Experience

Education

Check all that apply and enter name of school.
Did you graduate…?

High School
College
Nursing School
Technical Training

Languages spoken in addition to English:

Can you perform all of the job-related functions of the position(s)
for which you are applying?

If no, please explain:

Do you have current CPR certification?

Expiration date:

Past & Present Employers

Current Employer

Name: Position: Supervisor:

Date Started:

Salary:

Address 1: Address 2: City: State:

Zip Code:

Home Phone Number:

May we contact?

Past Employer

Name: Position: Supervisor:

Date Started:

Date Ended:

Reason for Leaving:

Salary:

Address 1:

Address 2:

City:

State:

Zip Code:

Phone Number:

May we contact?

References

Give work or medical field related references. Do not list relatives or personal friends.

Reference 1

Name: How I know: Years acquainted: Address 1: Address 2: City: State:

Zip Code:

Phone Number:

Reference 2

Name: How you know: Years acquainted: Address 1: Address 2: City: State:

Zip Code:

Phone Number:

Criminal Background Inquiry

Have you ever been convicted of a crime, other than a minor traffic offense, or pled no contest to a crime?

If yes, please explain:

You will not be denied employment solely because of a conviction record, unless the offense is related to the work for which you have applied.

Emergency Contact

Name: Relationship to you: Address 1: Address 2: City: State:

Zip Code:

Phone Number:

By checking the "I accept" box I affirm that the facts contained in this application are true and complete and to the best of my knowledge and I understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed above to give you any and all information they may have, personal or otherwise, and release all parties from all liability for damage that may result from furnishing same to you.

I accept

Companions For Seniors
6160 N. Cicero Avenue
Suite 402
Chicago, IL 60646

866-910-9020 phone
773-725-9900 fax
info@companionsforseniors.com

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For Companions

Personal Information

Employment Information

Qualifications & Experience

Education

Past & Present Employers

Current Employer

Past Employer

References

Reference 1

Reference 2

Criminal Background Inquiry

Emergency Contact

Availability Form

Questions?