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At-Home Job Registration

*required fields
*Date Registered:
/ /
*Name:
*55 or Older:

    

*Street:
*City:
*Zip:
*Home Phone:
Cell Phone:
Work Phone:

E-mail:
*Job Type:
PT    FT    Temp
Hours:
:00  through  :00
Days:
 Mon    Tu    Wed    Th    Fr    Sat    Sun
Travel:
 Car    Truck    Bus    Ride

Voluntary

In order to meet State and Federal reporting requirements, we are requesting that you voluntarily supply the following information. This data will not be considered in the evaluation of your application.

Race/Ethnic Data
Black (not of Hispanic Origin): Persons having origins in any of the black racial groups of Africa.
Hispanic: Persons of Mexican, Puerto Rican, Central or South American or other Spanish culture or origin, regardless of race.
White (not of HIspanic Origin): Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
American Indian or Alaskan Native: Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Asian or Pacific Islander: Persons having origins in any of the original peoples of the Far East, Southeast Asia the Indian Subcontinent or the Pacific Islands. This area includes, for example, China, Japan, the Philippine Islands, and Samoa.

Carpentry/Handyman

CHIC License

Inside    Outside    Repair    Build
Door Molding    Crown Molding
Sliding Doors    Pre-hung Doors
Windows: Replace    Reglaze    Rope Sash
Hatchways    Sheds    Decks    Siding
Mail Box Posts    Fences
Gutters: Install    Repair
Weather-Stripping
Railings    Shelving
Curtain Rods / Curtains
Blinds    Shades    Closet Clothes Rods
Hang Pictures    Shelves    Cabinet
Furniture Repair    Antiques
Door Locks    Window Locks

Plumbing - Licensed?

Unclog Drains    Fix Leaks
Sink Faucets: Repair    Replace
Replace Toilet Internal Parts
Shower : Repair    Replacement
Garbage Disposal: Repair    Install
Dishwasher Plumbing Repairs
Refrigerator Icemaker Plumbing Repairs
Outdoor Spigots

Electrical - Licensed?

Door Bells: Install    Repair
Replace Electrical Fixtures
Ceiling Fans: Install    Repair
Thermostats    Outlets
Smoke/CO2 Detectors    Small Appliance Repair
Porch/Driveway/Garden Lighting
Garage Door Opener: Install    Repair
Alarm System: Install    Repair

Masonry
Exterior    Interior
Repair Steps (brick/concrete/stone)
Patch Cracks & Crevices
Repair Walls
Tiles: Walls    Floors    Countertops
Regrouting Tubs/Showers

Painting/Staining
Exterior    Interior    Entire Home
Decks    Fences
Porch Grating
Walls    Doors    Ceilings    Trim
Wallpaper: Remove    Install

Groundswork
Gardening    Weeding    Landscaping
Mowing    Raking    Have Own Equipment
Trim Bushes    Prune
Gutters: Clean    Repair
Snow: Shoveling    Blowing    Removal
Clean Out Basements/Garages/Attics
Hauling/Dump Runs
Wash Windows/Screens
Powerwash

Driver/Chauffeur
Car    Wagon    Van
Own Car    Customer's Car Only
Airports: Bradley    Lag/JFK    Newark    Logan
Casinos: Mohegan Sun    Foxwoods
Weekdays    Weekends
Local (list towns or cities)
CT    RI    MA    NY    NJ
CDL    PSL    Insurance

Companion - CNA    HHA    NA    CPR

Cooking: Light    Full Meals
Cleaning: Light    Full
Shopping: Medication    Groceries    Clothing
Drive to Doctor's Appointments/Shopping
Dispense Medications    Oxygen
Take Temperature Pulse    Blood Pressure
Supervise Range of Motion/Other Exercises
Bathing: Spongebath    Shower/Tub
Hair: Shampoo    Groom/Style
Change Bedding    Do Laundry
Wheelchair Transfer    Lift From Bed or Chair
Use Hoyer Lift
Speak Another Language?

Full Time    Part Time

Temporary    Permanent
Days    Nights    Evenings
Weekdays    Weekends
Live-in
Car    Bus    Ride
Gender Preference: Female Male
Is a Smoker?    Work with a smoker?
Work with a Dementia Patient?
Lifting Restrictions?
Pets OK?
Children OK?
Experience: Hospital    Nursing Home    Rehabilitation

Housework
Dust    Vacuum
Wax/Polish Floors
Clean Bathrooms
Clean Blinds    Wash Windows
Change Bedding
Laundry Ironing
Cooking: Light    Full Meals
Dishes
Full Time    Part Time – Pets OK?
Locations

Childcare
Age Range -
Diapers
Disabled/Handicapped
Dispense Medication
Cooking: Light    Full Meals
Driving: Own Car    Customer's Car
Pets OK?
Full Time    Part Time
Full Day    After School    Evenings    Overnight
Locations

Housesit/Petsit
Overnight    Long Term
Pet Care
Houseplant Care    Garden Care
House Checks
Other Responsibilities
Locations

Tutoring
Elementary    Middle    Highschool    Adult
Math    Reading    Art    Music
ESL    Spanish    Hebrew    Other
PC Applications: Word    Excel    Access    PPT
Summers Only
Translation: Language
Locations

Seamstress/Tailor
Alterations
Hems    Zippers
Dressmaking
Curtains/Drapes    Quilts
Upholstery    Pillows
Knitting    Crocheting
Lessons

Computer Clerical

Setup: IBM    Mac
Software Installation    Repair    Virus Cleanup
Instruction: Basic    Advanced
Quickbooks    Quicken
Bookkeeping    Balance Checkbook
Organize Medical Papers
Write Letters

Personal Care

Haircutting: Women    Men
Hair Color: Semipermanant    Permanent
Nails: Manicure    Pedicure    Polish
Other:

Other Skills

Employee Job Registration
At-Home Job Registration
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