Caregiver Applicant Form

Personal Information

* First Name

*Last Name

* Email

* Address Line 1

Address Line 2

* Country

* State/Province

* City

* Zip/Postal Code

*Gender

* Mobile Phone

* Home Phone

*Date of Birth

* SSN

Educational Background New Educational Background

School/College/University

Qualification

Attach Document

Minimum one certificate is mandatory to be filled.

Certifications

Please upload resume here

Browse

Employment History New Employment History

Please provide your latest employer information below.

Employer Name

Phone Number

Address

Country

State/Province

City

Zip/Postal Code

Served From

Served To

Position Held

Attach Document

Skills/ Preferences

Language

English

Italian

Spanish

References New Reference

Name

Phone Number

Miscellaneous Questions

Q.) Are you at least 18 years old?

Yes

Q.) Are you comfortable learning new software programs and using your own laptop and cell phone for your work?

Q.) Are you comfortable using public transportation with clients?

Q.) Are you comfortable with a job that requires you to take detailed notes on your work and report your daily activities?

Q.) Are you able to manage as a 1099 employee, including paying your own taxes without employer assistance?

Q.) Are you interested in working from home?

Prefer in-person work

Yes, exclusively

Yes, sometimes

Q.) Are you willing to be finger-printed with Minnesota Department of Health and Human Services?

Q.) Our clients come from a variety of linguistic backgrounds. Please tell us what you wish about your own linguistic background, including home languages or learned languages

Q.) What are you most curious about when it comes to housing stability?

Q.) How did you learn about Nexa Home Connect?

Caregiver Application Form