* Required Information
Personal Details
Alternate Contact

Most clients require transportation, often using the Caregiver vehicle:



Please indicate which of the following skills you are prepared to provide if referred to seniors / families:

Work History

Please provide at least five years of recent, verifiable work history followed by verifiable references.

Add Work History
Professional References
Add Reference

I certify that I have read and understand the general requirements of S & S Private Home Care on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I completely understand that I am submitting this Application as an interested Caregiver and that by submitting this there is no guarantee for employment. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, work, criminal and credit history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information.