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:

Name
Date of Birth (MM-DD-YY):
List any other names you have used and/or worked under,
including Maiden names
Gender: MaleFemale Race (optional):
Present Address:

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

Permanent Address:

(if different from current 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?
YesNo


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?
YesNo
If yes, do you have liability and medical coverage for your automobile?
YesNo
If yes, in what amounts?
Liability:
Medical:
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