Date: 4/21/2014

Application Form

Visiting Angels

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age sex, religion, disability, medical condition, national origin, or marital status.

Personal Information

First Name * Address 1 *
Last Name * Address 2
City *
Home Phone * Zip *
Work Phone Driver's License #
Mobile Phone
Email *

Section 1 - General Information

Number Question Effective Date Expiration Date
1 Do you have at least two years experience working with the elderly? (required)  
2. Job Type Desired? (required)  
3. Are you willing to do live-in?  
4. Can you provide documentation of a driver's license and auto insurance? (required)  
5. Date available to begin working? (required)  
6. Have you ever been convicted of, or plead guilty or no contest to, a misdemeanor or felony in the state of Texas or any other? (required)  
7. If yes, please explain.  
8. Do you own your own car? (required)  
9. What is your means of transportation?  
10. Are you a smoker? (required)  

Section 2 - Employment Verification

Number Question Effective Date Expiration Date
1. Are you authorized to work in the U.S.? (required)  

Section 3 - Other Training: Certifications/Licenses

Number Question Effective Date Expiration Date
1. Certifications/Licenses:  

Section 4 - Skills Inventory Checklist

Number Question Effective Date Expiration Date
1. Companionship  
2. Dementia/Alzheimer's  
3. Toileting  
4. Bathing/Showering  
5. Transferring  
6. Transportation/ Drive Clients  
7. Hoyer Lift  
8. Cooking  

Section 5 - About You

Number Question Effective Date Expiration Date
1. Tell us about one of your recent caregiving experiences.  
2. How did you hear about Visiting Angels?  

I certify that information contained in this application is true and complete. I understand that false information may be grounds for not hiring me or for immediate termination of employment at any point in the future if I am hired. I authorize the verification of any or all information listed above.