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 YesNo Has your Driver's License ever been revoked or suspended?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