Caregiver Application

To apply as a companion, please fill out the form below:

Full Name (required)

Address (required)

City(required)

Zip(required)

Your Email (required)

Home Phone(required)

Cell Phone

Please select the position you are interested in:

Are you over 18?
YesNo

Do you have a valid New York State Driver's License?
YesNo

Has your Driver's License ever been revoked or suspended?
YesNo

Do you own a car?
YesNo

What shifts would you prefer?
DayAfternoonEveningsLate-Night

Areas willing to travel:

Previous Experience

Business Reference #1 (People you have worked for.)

Business Reference #1 Phone Number

Date of Hire

How Long Were You Employeed?

Reason for Leaving


Business Reference #2 (People you have worked for.)

Business Reference #2 Phone Number

Date of Hire

How Long Were You Employeed?

Reason for Leaving


Character/Personal Reference (Not a family member.)

Character/Personal Reference Phone Number

What is your relationship?

Length of Relationship?

How did you hear about us?