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718-453-8400
Fax: 718-453-9391
info@bshha.org
992 Gates Ave. 2nd Floor Gates Avenue Brooklyn, NY 11221
Office Hours: MON to FRI 9:00 - 5:00
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Home
About Us
Services
Personal Home Care
Home Health Aide Services
Care Coordination
Career
Services Areas
Blog
Forms
State Withholding Form
Federal Withholding Form
Nurse Intake Form
Contact
Quick Inquiry
Step
1
of
5
20%
BSHHA
Home Care Agency
Personal Information
First Name
(Required)
Middle Name(s)
Last Name
(Required)
Address 1
(Required)
City
(Required)
Email
(Required)
Home Phone
Cell Phone
(Required)
Open to Live-In Care
(Required)
Yes
No
Convicted of a felony?
(Required)
Yes
No
Gender
(Required)
Male
Female
Vehicle Information
Vehicle Year
(Required)
Vehicle Make
(Required)
Drivers License
(Required)
Yes
No
Experience
Experience
Alzheiermer's
Bed Bath
Cancer
Combative
Dementia
Dementia Experience
Gait Belt Experience
Glucose Monitor
Hospice
Hospice Experience
Hoyer Lift Experience
Incontinence
Parkinson's
Stroke
Have you had a TB test in the last 3 Years?
Yes
No
Result:
Positive
Negative
Work Preference
Date
MM slash DD slash YYYY
Ideal Number of Hours Per Week
Expected Rate of Pay/hr
(Required)
Shift Availability
Monday
Morning
Afternoon
Evening
Live-In
Tuesday
Morning
Afternoon
Evening
Live-In
Wednesday
Morning
Afternoon
Evening
Live-In
Thursday
Morning
Afternoon
Evening
Live-In
Friday
Morning
Afternoon
Evening
Live-In
Satuday
Morning
Afternoon
Evening
Live-In
Sunday
Morning
Afternoon
Evening
Live-In
Education
School Name
Subject Studied
Years Attended
Location
Degree
School Name
Subject Studied
Years Attended
Location
Degree
Reference
First Reference
Name
Relationship
Phone
Years Known
Second Reference
Name
Relationship
Phone
Years Known
Describe any personal, volunteer or work related experience that will help you in this position:
Employment History
Present/Last Employer
Employer Name
Telephone
Supervisor's Name
May we contact
(Required)
Yes
No
Address
Position Title
From Date
MM slash DD slash YYYY
To Date
MM slash DD slash YYYY
Summary of Duties
Reason for Leaving
Previous Employer
Employer Name
Telephone
Supervisor's Name
May we contact
Yes
No
Address
Position Title
From Date
MM slash DD slash YYYY
To Date
MM slash DD slash YYYY
Summary of Duties
Reason for Leaving
Certify
By signing this application, I certify this information to be true and agree to allow the above mentioned BSHHA to perform a criminal history background check, at their leisure, and I give permission for them to check my reference.
Full Name
(Required)
Date
(Required)
MM slash DD slash YYYY
Signature
CAPTCHA
Schedule Appointment
Name
(Required)
Email
(Required)
Phone
(Required)
Your Message
(Required)
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