Call us today at 717-489-1700

"Compassionate and efficient in-home care for the people you love"

Thank you for your interest in joining our growing family of caregivers.
Please complete the form below and we will promptly review your application.

Position Desired

What position(s) are you interested in?

Caring for the elderly
Caring for persons with disabilities
Housekeeping
Preparing meals

Would you prefer to live with the family in their home?

Yes ("live-in")       No ("live-out")

Your Contact Information

Last name:

First name:

Gender: Male     Female

Street address:

City:

State:

Zip code:

Country:

Phone (include country code and city/area code):

Mobile phone (include country code and city/area code):

Fax (if available):

Email:

About You

Date of birth:

Place of birth (city, country):

Country of citizenship:

Knowledge of English

Very good   Good   Fair

Other languages spoken:

Religion:

Height:

  ft

Weight:

  lbs

How is your general health?

Marital status:

Number of dependents:

Highest education/training (level/degree, discipline):

Mother's occupation:

Father's occupation:

Your Work Experience

What housework have you done in the past?

Doing laundry
Ironing
Cooking
Baking
Waiting at table

If you have brothers or sisters, what ages are they?

Do you have a driver's licence?

Yes      No

If yes, for how long?

  years

Have you taken care of children / the elderly / persons with disabilities?

Yes      No

What ages?

Do you like pets?

Yes      No

Do you have any allergies?

Do you smoke?

Yes      No

If yes, how many cigarettes a day?

Do you swim?

Yes      No

What outdoor sports, if any, do you like?

What are your hobbies and interests?

Do you prefer a household with few or many children?

Few (1-3)       Many (4 or more)

Ages preferred:

Where would you prefer to work?

City   Suburb   Small town   Rural area

Do you have relatives or friends living in Pennsylvania?

Yes (provide details below)      No

Name:

Relationship:

City, province:

 Phone:

May we call?

Yes   No

Yes   No

Yes   No

Your Present Employer

Present employer's name:

 City, country:

 Phone:

May we call?

Yes   No

Duties:    From:    To: 

Reason for leaving: 


Previous employer's name:

 City, country:

 Phone:

May we call?

Yes   No

Duties:    From:    To: 

Reason for leaving: 


Previous employer's name:

 City, country:

 Phone:

May we call?

Yes   No

Duties:    From:    To: 

Reason for leaving: 

Other Important Details

Do you have a valid passport?

Yes      No

Are you able and willing to sign a one-year contract?

Yes      No

When are you available to start work?

Have you applied previously for a work permit for U.S.?

Yes      No

Was your application for a work permit ever refused?

Yes      No

If yes, for what reason?

Please feel free to elaborate on any of the above if you wish, or describe any other relevant experience you have.

Finally, how did you hear about us or who referred you to this website?

By entering my name below and submitting this Caregiver Application Form, I confirm that the information I have provided herein is correct and complete to the best of my knowledge, and I consent to the use of this information by Benevolent Heart LLC and its agents for the purpose of verifying the information and providing or facilitating the services I am requesting.

Electronic signature (enter your full name):

 


Contact Us

Give us a call, email or visit us at:


BENEVOLENT HEART
ASSISTED LIVING
1037 Swarthmore Rd.
New Cumberland, PA 17070

Phone: (717) 489-1700

Email : info@BenevolentHeartLLC.com

Look for:
Marc Banzali
Manager/Administrator

 

Business hours:

Mon-Fri, 9am-5pm

 

licensed and insured in the
State of Pennsylvania