Open 24 Hours: Serving Southern California since 1991

(310) 657-8780
(562) 929-8400
(949) 650-3800

Caregiver Referral Application

Requirements

  • Required 2 Years of Caregiver Experience
  • Must be able to read and write English
  • Must be legally able to work in United States

Documents that you will need to bring to our office after completing form below:

  • Valid California Driver’s License or California I.D.
  • Social Security Card
  • Proof of CPR Training (less than 2 years old)
  • Proof of Tuberculin Test (less than 1 year old)
  • Proof of Automobile Insurance & Registration (if you drive)
  • U.S Passport
  • Letters of Recommendations
  • Certifications

Contact Information

Full Name (required)

Address

Email (required)

Home Phone Number

Cell Phone Number

May We Contact You at Work?
 Yes No

Work Phone Number

If Yes, What is the best time to reach you? eg: 3:00 PM

General Information

If under 18, can you provide a work permit?
 Yes No

If no, Please explain:

Have you submitted an application previously?
 Yes No

If Yes, when did you last apply? give date(s)

Have you been employed with A-1 Home Care Agency before?
 Yes No

If Yes, when did you last work here? give date(s)

Are you legally eligible to work in the United States of America?
 Yes No

Dates available to work:

Position desired:
 Full-time Part-time Temporary Live-In Hourly

Referral

How did you hear about us?

Note: Policy requires all applicants also fill out an application in person at our corporate headquarters.
The information above is an exact copy of what will be asked on our paper application. If you''d like, please print this page for easy reference when called for an interview.