Contact Information

Name* 

Email Address *

Address *

Home Phone *

Cell Phone *

Other Phone *

Social Security #* 

 I would like a job as a full-time live-in Companion

Days I can Work:  MON  TUE  WED  THU  FRI  SAT  SUN

 I would like a job as a live-out Companion

Days I can Work:  MON  TUE  WED  THU  FRI  SAT  SUN

Driver's License

State

License #

High School

Name

State/Country

Year

College

Name

State/Country

Year

Personal References

Give the names of three people you have worked with who are not related to you

Name *

Telephone *

Occupation *

Name *

Telephone *

Occupation *

Name *

Telephone *

Occupation *

Employment History

List present and past employment with most recent first. EXPLAIN ANY PERIODS OF UNEMPLOYMENT LONGER THAN THREE MONTHS

Employer 1

Start Date

End Date

Employer

Job Title

Address

Reason for Leaving

Employer 2

Start Date

End Date

Employer

Job Title

Address

Reason for Leaving

Employer 3

Start Date

End Date

Employer

Job Title

Address

Reason for Leaving

I HEREBY AUTHORIZE BRIGHTER & BETTER LIVING TO REQUEST AND RECIEVE FROM ALL PRIOR EMPLOYERS WITHIN ONE YEAR OF THE DATE OF THIS APPLICATION ANY AND ALL PERTINENT INFORMATION CONCERNING MY PRIOR EMPLOYMENT AND ITS TERMINATION, INCLUDING THE REASONS FOR SUCH TERMINATIONS. I hereby state that all the information I have provided is atrue and complete statement of the facts. False statements contained in this application are immediate cause for dismissal from registrant caregiver status. I further give permisison for this agency to verify all schooling and references.