* denotes a REQUIRED field
Last Name *
First Name *
Middle
Street Address * Street, City, State
Mailing Address * If less than 5 years at current physical address
Previous Address *
Email Address *
Home Telephone *
Cellular/Mobile Phone
Emergency Contact Person *
Phone Number *
Are you 18 or older? *	YesNo
Employment Information *	YesNo
Do you have at least one (1) year care-giving experience with an agency for a private individual, other than family or friends?
Positions Desired Place a checkmark on the position(s) you wish to apply.	Home Health Aide Certified Nurse's Aide Companion Homemaker/Chore-worker Registered Nurse (RN) LPN/LVN Admin. Staff
Days Available to Work Place a checkmark on the days you are available.	No Preference Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Hours Available to Work If you can only work certain hours on certain days, please list them here.
Are you available for work on Holidays? *	YesNo
MetroCare Hawaii LLC requires caregivers to work on weekends and holidays.
Date available to start work *
Shift Preference	MorningAfternoonEveningGraveyard
Amount of Wage (current) or last paid
Wage Currently Seeking
Briefly describe your experience as a caregiver (List any applicable experience) *
Have you ever applied here before? *	YesNo
Have you ever been convicted of a felony? *	YesNo
Do you possess a valid Hawaii Driver's License? *	YesNo
Do you have access to reliable transportation? *	YesNo
State of Issue *	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
Have you had any accidents during the past three years? *	YesNo
How Many? *
Have you had any moving violations in the past three years? *	YesNo
How Many? *
Do you have current CPR/First Aide certification? *	YesNo
Expiration Date
Have you ever had a TB skin test? *	YesNo
Date of most of recent test
Are you allergic or afraid of cats and/or dogs? *	YesNo
Are you able to transfer someone from a wheelchair into a car or onto a bed? *	YesNo
Please describe your skills/strength/what people like about you, which make you a good candidate to be a member of our professional staff. *
Which of the following areas can and will you travel to?	North Hilo South Hilo Puna Kau North Kona South Kona South Kohala North Kohala Hamakua Central Oahu Windward Oahu North Oahu South Oahu West Oahu
Education
Please list the name of your School, its location, number of years completed as well as Major/Degree attained.
High School
College
Business or Trade School
Professional School
Are you a CNA? *	YesNo
Expiration Date
Work Experience
Please begin with your most recent employer. Please list the name of your employer, their address, phone number, employment dates and Pay Rate.
Current/Former Employer *
May we contact your supervisor?	YesNo
Position and Job Duties *
Reason for leaving (Please be specific) *
Former Employer I
May we contact your supervisor?	YesNo
Position and Job Duties
Reason for leaving (Please be specific)
Former Employer II
May we contact your supervisor?	YesNo
Position and Job Duties
Reason for leaving (Please be specific)
References
Please list a minimum of 2 work related and 2 personal references. Please list their name, phone number and relationship to you.
References I(Personal) *
References II(Personal) *
References I(Work Related) *
References II(Work Related) *
Certification and Release *
Please read our disclaimer and agreement information below, if you agree to ALL the terms, please put your initials in the box. You must place your initials in the box to submit this form.
* Security Code