For Companions

Job Application

Please complete this application as completely and accurately as possible.

Download this Form

Personal Information

Optional

Optional

Optional

Optional

  • Yes

  • No

  • Yes

  • No

  • Yes

  • No

  • Yes

  • No

Employment Information

Optional

  • Part Time

  • Full Time

Optional

Optional


  • Yes

  • No

Optional


  • Yes

  • No

  • Yes

  • No


Qualifications & Experience

Education

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

  • High School

  • College

  • Nursing School

  • Technical Training



  • Yes

  • No


  • Yes

  • No



Past & Present Employers

Current Employer

  • Yes

  • No

Past Employer

  • Yes

  • No



References

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

Reference 1

Reference 2



Criminal Background Inquiry

  • Yes

  • No

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

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

© 2011 Companions for Seniors, Inc. All Rights Reserved.