OPTIMI Home Care, Inc. Application for Home Care Aides/CNA’s

This employer does not discriminate in its hiring decisions or in any other employment decision on the basis of race, color, religion, citizenship, national origin, sex, ancestry, military status, sexual orientation, familial status, age or upon a physical or mental disability which is unrelated to the applicant’s/employee’s ability to perform the essential functions of the position.

To download a printable pdf version of this application please click here.  To complete the application online please complete the form below.

    Date of Application (MM-DD-YY):

    Date Available to Start Work (MM-DD-YY):

    Personal Information:


    Date of Birth (MM-DD-YY):

    List any other names you have used and/or worked under,
    including Maiden names

    Gender: MaleFemale

    Race (optional):

    Permanent Address:

    (if different from current address)

    Present Address:

    (Street #/Street name/City/State/Zip)

    E-Mail Address:

    Home Phone (xxx-xxx-xxxx):

    Mobile Phone (xxx-xxx-xxxx):

    Does mobile phone accept texts: YesNo

    Emergency Contact Person Name and Phone

    Emergency contact’s relationship to applicant

    Languages Spoken (list all in which you are fluent)

    How far are you willing to travel for an assignment
    (check all that apply):
    less than 10 miles10-20 miles20-30 milesover 30 miles

    Do you have a car available to you for work?

    If no, how will you get to work?

    If yes, can you use this car to drive your client while you are on the job?

    If yes, do you have liability and medical coverage for your automobile?

    If yes, in what amounts?


    Who is your insurance Company?

    Do you have a valid driver’s license? YesNo

    Have you had your finger-print-generated criminal background check done within the past year? YesNo

    If yes, please provide the date