Exit Pre-Application Form Question Title 1. Please enter your contact information below: First Name * Last Name * Address * Address 2 City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Email Address Phone Number * Question Title 2. When was the last time you worked at a home care agency? More than 2 years ago Within the past two years but not currently Currently working at a home care agency Question Title 3. Please indicate your work availability and preferences, if any, below? (Select all that apply) Full-time Part-time 4-hour shifts 8-hours shifts 12-hour shifts Live-in No weekend shifts No pets (cats, dogs, etc.) Non-smoking clients Question Title 4. Do you have any restrictions that may deter you from taking an assignment? No Yes (please specify) Question Title 5. How did you come to know about employment opportunities at Neighbors Home Care Services? Flyer Signage Referral Online Other (please specify) Done
