I understand before I can be considered for a position with Home Companions Senior Care
I must have met the following requirements:

Digital Finger Printing (within the last two years)

Current CPR Card (within the last two years)

Valid Florida Drivers License

Valid Florida Auto Insurance

Valid Auto Tag/Registration

Proof of Alzheimer's and Related Dementia training (within the last two years)

Proof of Assistance with Self-Administered Medication (within the last two years)

Proof of HIV/Aids training (within the last two years)

Proof of C.N.A. Training

Valid Florida C.N.A. License

Proof of Home Health Training
I am applying for a position of:
Certified Nursing Assistant/HHA
Application Date:
Applicant Name:
Social Security #
Applicant Email Address:
Applicant Cell Number:
Applicant Telephone:
Applicant Physical Address:
include: city, state, zip code
Applicant Mailing Address:
include: city, state, zip code
Background Checks
Home Companions of Lake County Inc, conducts a thorough background investigation and employment
screening process on all applicants being considered for employment, including, but not limited to,
employment and personal references, FDLE, MVR, education, certifications, licenses and court records. We
reserve the right to utilize this information in any way deemed necessary to make a final determination of
employment.
Yes
No
Have you ever been arrested?
Have you been convicted of a felony?
No
Yes
Are you a citizen of the United States?
No
Yes
Are you an alien with legal work status?
Yes
No
Education and Skills related to position you're applying for:
Technical School Name and Location     Year (s) Attended     Certificate/ Degree      Florida License#
Activities of Daily Living Skills:
Bathing         Dressing           Eating           Toileting           Continence         Ambulation
Instrumental Activities of Daily Living Skills:
Cook/Serve a Meal  Doing Laundry Grocery/Household Shopping Vacuuming  Dusting Driving Set Appts
Grooming and Hygiene Skills:
Mouth Care Brushing Teeth Soak/Clean Dentures Shampoo Hair File Nails Foot Bath Moisturize Skin
Functional and Cognitive Impairment Skills:
Diversion Techniques        Distraction Technique       Social and Recreation Activity Skills
Essential Clinical Skills:
Blood Pressure  Pulse: Apical Radial  Temperature: Oral  Axillary  Respirations  Range of Motion
Adaptive Aids and Mobility Equipment
Crutches, Cane, Quad Cane, Walker, Wheelchair, Power Chair, Hearing Aids, Leg Prosthesis, Hoyer Lift
Driving and Transportation is a task that may be required to drive a client in their car or your car to
a medical appointment or other essential errands such as: shopping, to the bank or post office.
Do you agree to this requirement?
Yes
No
Do you have a reliable vehicle?
No
Yes
Employment History last position held related to the position applying for:
Name of Employer:

Direct Supervisor:

Date Employment Stated:

Position Held:

Responsibilities:

Date Employment Ended:

Reason for Leaving:

May we contact for reference:
No
Yes
Using the simple 'click' box, click the box next to the
week day; select the time you would like to work.

Thursday          

Friday         

Saturday         

Sunday          

Monday       

Tuesday          

Wednesday
Comments:
We are a family owned and operated
home care agency with over 20 years of
experience.

We are always looking for caregivers who
are reliable and can interact and engage
older adults.   

If  you are  dependable, conscientious, and
helping others is your calling, complete our
application.

If you meet the criteria we're looking for we
will contact you.
Copyright © 2000-2012 Home Companions of Lake County , Inc   All rights reserved
Let Us Help You Make Home Possible | Available 24 Hours
Lake County and Surrounding Areas |
(352) 483-3086