Sonoma Homecare: Home Care Services for Sonoma County, Napa County, Oakmont, Santa Rosa, and Surrounding Communities

fill out the form below if you would like to join our team of caregivers

APPLICATION FOR REGISTRATION

Full Name

Address

City

State & Zip

Home Phone

Mobile Phone

Alternate Phone

E-mail

E-mail (confirm)

Are you 18 years of age or older?

Yes No

What type of job are you interested in?

Full-time Live-In Companion
Full-time Live-Out Companion

What days are you available to work?

Mondays	Tuesdays
Wednesdays	Thursdays
Fridays	Saturdays
Sundays	Holidays

If you are interested in working as full-time Live-Out Companion, describe your hours of availability:

How did you hear about
Sonoma Homecare?

Do you have a valid driver's license?
If yes, what state, and number?

Yes No
State #

EDUCATION

High School Name

State or Country

Did you graduate?

Yes No

College Name

State or Country

Did you graduate?
If yes, what degree?

Yes No

Do you have any certifications or licenses related to the medical or homecare industry?

RN       LVN
CNA      CCA
CSA      CPR/FirstAid

REFERENCES
Please provide contact information of three persons that you have not worked with, and are not related to you:

Name

Phone
Occupation

Name

Phone
Occupation

Name

Phone
Occupation

EMPLOYMENT
Please list present and past employment, beginning with most recent:

Job title

Dates of employment

From: To:

Employer name

Employer address

Reason for leaving

Duties performed

- - - - -

Job title

Dates of employment

From: To:

Employer name

Employer address

Reason for leaving

Duties performed

- - - - -

Job title

Dates of employment

From: To:

Employer name

Employer address

Reason for leaving

Duties performed

- - - - -

Please explain any gaps of employment greater than three months and/or further relevant experience:

ACKNOWLEDGEMENT/AUTHORIZATION

By checking the box below, you, the applicant, HEREBY AUTHORIZE SONOMA HOMECARE TO REQUEST AND RECEIVE FROM ALL PRIOR EMPLOYERS WITHIN ONE YEAR OF THE DATE OF THIS APPLICATION, ANY AND ALL PERTINENT INFORMATION, CONCERNING MY PRIOR EMPLOYMENT AND ITS TERMINATION, INCLUDING THE REASONS FOR SUCH TERMINATIONS. I hereby state that all of the foregoing information I have supplied in this application is a true and complete statement of the facts. False statements contained in this application are immediate cause for dismissal from registrant caregiver status. I further give my permission for this agency to verify all schooling and references.

I understand that part of the application process includes the completion of a 10-panel drug test, criminal background check, and department of motor vehicles license review. This must be completed before I can work for any clients of Sonoma Homecare.

I acknowledge and authorize as stated above

This agency is a member of Companion Connection Senior Care