Tender Home Care
Oregon In-Home Care Company
2225 NW Stewart Parkway Suite #102
Roseburg, Oregon 97471
Phone:(541) 229-6848 Fax: (541) 391-4026
www.tenderhomecare.com

At Ease Home Care
Oregon In-Home Care Company
1430 Pearl StreetEugene, Oregon 97401
Office (541) 344-3273
www.ateasehomecare.com

Caregiver Application

Incomplete Applications Will Not Be Considered.
Please Read Entire Application.
Void 6 months after the "Date" entered below and will be shredded after 14 months.
According to Oregon Administrative Rules, Division 536; 333-536-0050, 9 "The in home care agency must insure that a criminal
background check has been conducted on all individuals employed by of contracting with the agency..." AEHC / THC holds to
the DHS guidelines ORS 443.004 reguarding specific convictions that prevent them from working with an in-home care agency.

* Indicates Required Fields

* Name:	* Date:
Address:	Apt #:
City State Zip
* Primary Phone	Secondary Phone
Cell Phone Carrier	* Email

How or Who Refered You?	Former Employee? Y N

Application at a Glance: (Check the box: Y=Yes and N=No)
1) In Home Care Experience	Y N	8) Current Drivers License?	Y N
2) Elderly Care Experience	Y N	9) Reliable Vehicle?	Y N
3) CNA,LPN,RN License?	Y N	10) Current Automobile Insurance?	Y N
4) License # Exp:		11) Bus Bike / Non-Driver?	Y N
5) Other Certifications:		12) Current TB Screening?	Y N
6) Can You Pass A Drug Test?	Y N	13) Oregon Food Handler's Certificate?	Y N
7) Do you have health insurance?	Y N	14) Through?

Skills Overview: (Check the box: Y=Yes and N=No. You may be asked where you received training/experience)
Charting	Y N	Alzheimer's Disease	Y N
Gate Belt	Y N	Dementia	Y N
WheelChair Transfers	Y N	Hospice	Y N
Hoyer Lift	Y N	Stroke	Y N
Toilet/ Incontinent Asst	Y N	Wound Care	Y N
Bathing	Y N	Cancer	Y N
Medication	Y N	Catheter	Y N
Range of Motion	Y N	Colostomy	Y N
Development Disabilities	Y N	Mental Illness	Y N
House Keeping	Y N	Feeding Tube	Y N
Other

Education:
High School Diploma or GED Y N
List College or Program Name, City and State, Dates, Subject or Degree
College/Program	City	State	Date From	Date to	Subject/Degree
1)
2)
3)

Personal References: (Incomplete Applications will not be considered. Phone numbers must be current.)
Provide three Personal References including Name, Relationship and Reliable Phone Number. No family members or former employers.
Name	Relationship	Phone
1)
2)
3)

Emergency Contact:
Name	Relationship	Phone
1)
2)
3)

Question:

Why do you want to work as a Caregiver for At Ease Home Care / Tender Home Care and what makes you a good Caregiver

Employers References: (Incomplete Applications will not be considered.) Phone and Fax Numbers must be current. Provide most recent employer first.
============== Employer #1 ==============
Employer:		Your Job Title:
Phone:	Fax:
Address City: State:
Dates Employed From To:		Supervisor:
Starting Wage $		Ending Wage $
Reason for Leaving / Are you eligible for rehire? Y N

Job Duties:

May we contact employer? Y N
============== Employer #2 ==============
Employer:		Your Job Title:
Phone:	Fax:
Address City: State:
Dates Employed From To:		Supervisor:
Starting Wage $		Ending Wage $
Reason for Leaving / Are you eligible for rehire? Y N

Job Duties:

May we contact employer? Y N

Personal History: (Provide the Following In Order to Accurately Complete Your Required Background Check.)
List Street, Address, Cities and States, and Dates Residing At These Locations:
Address	Date From	Date To
1)
2)
3)

List Other Name You Have Used and Dates You Used Them - Including Maiden Name:
Name	From Date	To Date
1)
2)
3)

Authorization to Obtain Your identify Verification Report / Background Check:
I hereby certify that the answers given by me to all the questions contained on this Employment Application are true
and correct to the best of my knowledge. If employed by At Ease Home Care / Tender Home Care, I will comply with all rules
and regulations of the company, I agree to submit to a physical and/or drug examination if required. I have
read and understand the purpose of this Employment Application. I also understand that if any fraudulent
information is given on this application it may be grounds for immediate termination from my position.
I am providing complete and accurate information. Pre-employment screening fees may be applied.

I authorize At Ease Home Care/Tender Home Care to obtain an Employment/Identity Report for employment purposes.
I understand that these inquiry reports may include but are not limited to: Conviction records, motor vehicle
records, references, and copies of prior personnel files. I understand that providing my Social Security number
and birthday is voluntary. I authorize the use of this information for the purpose of national and/or state criminal
history and background checks. I understand that I may be asked to provide further proof of idenity obtained from
the Social Security Department if requested At At Ease Home Care / Tender Home Care. is an Equal Opportunity Employer.
I understand that the job position I am applying for is placed equally without discrimination due to race, creed, color,
religion, sex, national origin, sequal preferences, handicap, or age.

*Name	*Date
*Signature	Social Security Number - -
Birthday

This authorization is given pursuant to the fair Credit Reporting Act. 15 U.S.C. 168 1(b)(2)(B). Note FCRA requires that an applicant must authorize in advance the procurement of an Employment/Identiry Verification Reqport for employment purposes.

Tender Home Care
Oregon In-Home Care Company
2225 NW Stewaqrt Parkway Suite #102
Roseburg, Oregon 97471
Phone:(541) 229-6848 Fax: (541) 391-4026
www.tenderhomecare.com

At Ease Home Care
Oregon In-Home Care Company
1430 Perl StreetEugene, Oregon 97401
Office (541) 344-3273
www.ateasehomecare.com

This Authorization to Obtain Employment Verification / History must be signed before we can
conduct References Checks on all Applicants.

AUTHORIZATION TO OBTAIN EMPLOYMENT VERIFICATION / HISTORY

I authorize my former and current employers to give any information they have regarding my
employment, whether or not it is on their records, to Tender Home Care. I hearby release Tender Home
Care and former current employers from all liability and any damages for issueing said information.

*Name	*Date
*Signature

You will receive an email of your questionnaire. Please be sure your email address is correct above.

Form Revised Nov 2021