* denotes a REQUIRED field

Last Name *
First Name *
Middle
Street Address *
Street, City, State
Mailing Address *
If less than 5 years at current physical address
Previous Address *
Email Address *
Home Telephone *
Cellular/Mobile Phone
Emergency Contact Person *
Phone Number *
Are you 18 or older? *
Employment Information *
Do you have at least one (1) year care-giving experience with an agency for a private individual, other than family or friends?  
Positions Desired *

Place a checkmark on the position(s) you wish to apply.
Home Health Aide
Certified Nurse's Aide
Companion
Homemaker/Chore-worker
Registered Nurse (RN)
LPN/LVN
Admin. Staff
 
Days Available to Work

Place a checkmark on the days you are available.
No Preference
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Hours Available to Work
If you can only work certain hours on certain days, please list them here.
Are you available for work on Holidays? *
Nurse Pro-Care requires caregivers to work on weekends and holidays.  
Date available to start work *
Shift Preference
Amount of Wage (current) or last paid
Wage Currently Seeking
Briefly describe your experience as a caregiver (List any applicable experience) *
Have you ever applied here before? *
Have you ever been convicted of a felony? *
Do you possess a valid Hawaii Driver's License? *
Do you have access to reliable transportation? *
State of Issue *
Have you had any accidents during the past three years? *
How Many? *
Have you had any moving violations in the past three years? *
How Many? *
Do you have current CPR/First Aide certification? *
Expiration Date
Have you ever had a TB skin test? *
Date of most of recent test
Are you allergic or afraid of cats and/or dogs? *
Are you able to transfer someone from a wheelchair into a car or onto a bed? *
Please describe your skills/strength/what people like about you, which make you a good candidate to be a member of our professional staff. *
Which of the following areas can and will you travel to?
North Hilo
South Hilo
Puna
Kau
North Kona
South Kohala
North Kohala
Hamakua
South Kona
 
Education
Please list the name of your School, its location, number of years completed as well as Major/Degree attained.
High School
College
Business or Trade School
Professional School
Are you a CNA? *
Expiration Date
 
Work Experience
Please begin with your most recent employer. Please list the name of your employer, their address, phone number, employment dates and Pay Rate.
Current/Former Employer *
May we contact your supervisor?
Position and Job Duties *
Reason for leaving (Please be specific) *
Former Employer I
May we contact your supervisor?
Position and Job Duties
Reason for leaving (Please be specific)
Former Employer II
May we contact your supervisor?
Position and Job Duties
Reason for leaving (Please be specific)
References
Please list a minimum of 2 work related and 2 personal references. Please list their name, phone number and relationship to you.
References I(Personal) *
References II(Personal) *
References I(Work Related) *
References II(Work Related) *
Certification and Release *
Please read our disclaimer and agreement information below, if you agree to ALL the terms, please put your initials in the box. You must place your initials in the box to submit this form.

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