An Equal Opportunity Employer

Companions Forever LLC offers equal employment opportunity to all applicants for employment and to all employees regardless of sex, age, race, color, religious creed, sexual orientation, national origin, ancestry, marital status, disability or other characteristic protected by state or federal law.

INSTRUCTION: If you need help filling out this application form please notify the person who gave you this form every reasonable effort will be made to meet your needs in a reasonable amount of time.

  • Complete all pages of this application
  • Print clearly. Incomplete not legible applications may not be accepted.
  • If more space is needed to complete any question, use comments sections on the back.
  • Application will be active for 90 days and retained for a 12 month period.
  • This is not an employee contract.

Personal Information

Your Address(es)

Please list your address(es) for the past three years and the years you have resided there:

Your Contact Information


Click here to view example of multiple schedules


You may choose multiple animals

You may choose multiple languages. ex. (english, spanish)

Job Related Skills

  • Homemaker
  • Companion
  • Incontinence Care



Never Few Times Many Times
Worked in a private home as a caregiver?
Successfully cooked for another person?
Given a bath or a shower?
Given a bed bath?
Dressed someone besides yourself?
Changed a bed linen with someone in it?
Used a Hoyer Lift?
Used a gait belt?
Drive someone to an appointment?
Moved a person in a wheelchair?
Worked with a terminally ill client?
Worked with Alzheimer's/Dementia?
Fed another person?
Worked w/Person who has depression?

Education Completed

Personal References

Please provide a minimum of 2 personal references with complete addresses. Don't list former employers or relatives. The individuals you list should know you for at least two years.

pre-employment background check authorization form

I, , understand that as part of the employment process, Companions Forever LLC needs to complete a background check on me regarding:

  1. Criminal record;
  2. Sex and Violent Offenders Record;
  3. Employment Verification;
  4. Education Verification;
  5. License Verification;
  6. Motor Vehicle Records;
  7. Personal/Professional Reference Verification;
  8. Medical Suitability;

Request For Previous Employment Verification And Consent

Please confirm your consent to each of the following by adding a check to each checkbox.

I authorize Companions Forever to make inquires of all my employers educational institutions and references connecting my prior employment, the verification of my educational background, and personal character. I further authorize all past employers educational institutions and all other individuals providing references to respond to verbal and written inquires from Companions Forever. I hereby release all such persons and agencies providing such information from any and all claims and damages connected with their release of the requested information. 

I certify that the facts contained in this application are true and complete to the best of my knowledge and I understand that if I have provided false or misleading statements it shall be grounds for dismissal regardless of when such information is discovered.

I authorize your company to investigate all statements and facts provided herein and to contact the employers, and the references I have listed. I hereby authorize each, any, all of them to provide you with any all information concerning me, whether personal or professional and release the company and them from liability for any damages claims or legal actions that I may otherwise be entitled to take as a result of investigation, use or disclosure of such information.

View the letter we may send to your previous employer

I certify that the statements made by me are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any Misstatements of fact, I am subject to disqualification, dismissal, or other action pursuant to employment agency policy and procedure, and subject to criminal penalties as prescribed by law.


Have you ever pleaded guilty, no contest to or been convicted of any criminal offense involving violence or dishonesty in any state or federal court? NOTE: You are not required to disclose an arrest, criminal charge, plea or conviction if the records have been erased under Conn.Gen. Stat. Sections 46b-146, 54-76o,or 54-142a. Records subject to such erasure are records pertaining to a delinquency or that a child was a member of family with service needs, youthful offenders, dismissed or nolled criminal charges, not guilty adjudications, or absolute pardons. Any person whose criminal records have been erased is deemed never to have been arrested and may swear so under oath.

If yes, give date, location and type of conviction or plea:

Have you ever been subject to any decision imposing disciplinary action by a licensing agency in any state, the District of Columbia, a United States possession or territory or a foreign jurisdiction?

If yes, give date, location and type of disciplinary action.


By signing below I acknowledge that I am submitting my application to Companions Forever, LLC and authorizing the pre-employment check and previous employer verification.


This serves only as an example of what we will send to your previous employer

The above referenced individual has applied to work for Companions Forever, LLC as a caregiver. The applicant will be working on client's homes, and at times may be unsupervised. The applicant has listed you as a reference.Please complete the information requested below about their dates of employment and their job performance so that we we will be able to maintain our high standards for offering the highest caliber personal. All information provided will be held in the strictest confidence. Kindly return your response by fax to (850) 956-9856 or call (850) 524-8550 and ask for join extension 234.Please verify the above information is accurate and complete the information below. Thank you!

Please rate employee in the following areas:

Criteria Excellent Good Average Poor
Ability of work
Job knowledge
Communication and ability to follow directions

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