Genki HomeCare
EMPLOYMENT APPLICATION
1260 Third Ave., Chula Vista, CA 91911
Phone (858) 699-7020
E-mail: info@genkihomecare.org
Web: www.genkihomecare.org

Name:___________________________________________

Address:_________________________________________________________________________________

Home Phone: ________________ Cell Phone: _______________ Email: _____________________________
Preferred Contact Method (Check all that apply): Home Phone , Cell Phone , Email 
Have you applied to Genki HomeCare in the past?
YesNo
If yes, give date(s), position(s), and outcome(s)? ___________________________________________________
Do you have any family member(s) and/ or relative(s) who work for Genki HomeCare?
YesNo
If yes, name(s) _____________________________________________________________________________How did you know about us?
Heard from a Genki member : name of the member _______________________,
Heard from a Kiku Gardens related member : name of the member _______________________,
Heard from a client or his/her related person : name(s) of the client (and the person if applicable)_______________________________________________________________________________,
Our Web , Ads  - the name of the media ____________________, Other ________________EMERGENCY CONTACT:
Name:_______________________________

Home/Cell Phone:

Relationship:_____________________________________________________________

Work Phone: _______________________________

RECORDS:
Are you at least 18 years old?
Do you have proof of your eligibility to work in the U.S.?
Do you have your valid social security number in the U.S.?
Do you consent to fingerprinting and background check?
Do you have your valid Driver License in the U.S.?
Do you have your valid car insurance in the U.S.?
Do you have a car?
Are you OK working around cats and dogs ?

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

NoNo
NoNo
NoNo
No
No

AVAILABILITY:
On what date will you be able to start to work? ____________________________________________________
Please indicate your preferred days and hours of availability:
MondayFromtoTuesday
FromtoWednesday FromtoThursday
FromtoFriday
FromtoSaturday
FromtoSunday
FromtoHow many days would you like to work?
_________________________________

1(09/2021)

How far are you comfortable to commute? _________ miles from your place or _________ -minute driving.
In what language(s) are you fluent? _____________________________________________________________SKILLS:
Have you assisted or performed the following tasks for seniors?
Companionship:

Yes

No

Change Clothes:

Yes

No

Bathing/ Showering:Yes

NoGrooming:

Yes

NoTransfer:

Yes

No

Laundry:

YesNoDriving:

Yes

No

House Cleaning:

Yes

No

Dementia Care:

Yes

No

Cooking:

Yes

No

Incontinent/ Peri Care:

Yes

No

Bed Linen Changes:

Yes

NoLifting:

No lifting

25 lbs or less25-50 lbs

50-75 lbs

75 + lbs

Are you willing to perform the following tasks for seniors?
Companionship:

Yes

No

Change Clothes:

Yes

No

Bathing/ Showering

Yes

No

Grooming:

Yes

No

Transfer:

Yes

No

Laundry:

Yes

No

Driving:

Yes

No

House Cleaning:

Yes

No

Dementia Care:

Yes

No

Cooking:

Yes

No

Incontinent/ Peri Care:

Yes

No

Bed Linen Changes:

Yes

No

Lifting:

No lifting25 lbs or less25-50 lbs

50-75 lbs

75 + lbs

CERTIFICATION:
Certified Nurse Assistant:YesNo
If yes, expiration date of certification: _____________
School Received Certification From: ___________________________________________________________
CA Home Care Aide (HCA) state registered: YesNo

If yes, date of registration : _____________CPR Certification:

Yes

No

If yes, expiration date of certification: _____________First Aid Certification:

Yes

No

If yes, expiration date of certification: _____________

Covid-19 Vaccination:

Yes

No

If yes, 2 nd dose on: _____________

Special skills, certificates, awards or courses:

Do you have any other training, experience, skills or qualifications that make you especially suited to theposition?

2(09/2021)

PROFESSIONAL REFERENCES:
List two references, not related to you, who may be contacted:
1. Name:Relationship:
Phone:OK to contact ? Yes

Email:
No

2. Name:Relationship:
Phone:OK to contact ? Yes

Email:
No__________________________________________________________________________________________YOUR RESUME:
Please attach your resume which includes your job history and educational background.
I certify that the statements made in this application are true and correct, and have been given voluntarily.
Signature:

Date:

3
(09/2021)