Cypress HomeCare Solutions

Call today for your free in-home care assessment

24/7 Helpline (602) 264-8009

  • Applicant Personal Information
  • Employment
  • Work History

Applicant Personal Information

In compliance with our obligations under federal and state law, we strive to consider the applicant for all positions without regard to race, color, religion, sex, national origin, age, marital status, sexual orientation or identity, veteran status, or the presence of a mental or physical disability, or other legally protected status. If any accommodations need to be made due to disability during our pre-hire process, please notify Cypress HomeCare Solutions (which will be referred to throughout as the “Agency”).

Employment, Referral, Training/Skills

How did you hear about this position?

Have you ever been employed by Cypress HomeCare Solutions before?

Are you 18 years of age or older?
Do you have any job related training or licenses? (Example: DCW, Certified Caregiver, C.N.A., etc.)

Do you have an Arizona Department of Public Safety Level 1 Fingerprint Clearance Card?


What type of work schedule are you looking for and where are you interested/available to work?

Hours Preference:

 Saturday Sunday Monday Tuesday Wednesday Thursday Friday

 Mornings Afternoons Evenings Overnights

Preferred Work Area: (Please check all that apply).

South West:

 Litchfield Park Tolleson Avondale Goodyear Buckeye (S) Palo Verde Tonopah

North West:

 Peoria Sun City Youngtown El Mirage Sun City West Surprise Wittman Wickenburg Buckeye (N)


 Phoenix (N) Glendale Paradise Valley Deer Valley Anthem New River

Downtown/South Central:

 Laveen Phoenix (Central)

North East:

 Scottsdale (N) Cave Creek Carefree Rio Verde Fountain Hills

South East:

 Scottsdale (S) Tempe Ahwatukee Chandler Sun Lakes Gilbert Higley Mesa Apache Junction San Tan Valley Queen Creek

Personal References

Please list the following information for three work references (co-workers, business associates, etc.) not related to you. These references should be in addition to the below current/former employers or supervisors. If not applicable, list three personal references not related to you.




Work Experience

Please list all employment for the past 7 years. Start with your most recent employment. Please complete even if you are submitting a resume. Attach additional sheets if necessary. Please account for any gaps in employment below.


May we contact?

Dates of Employment:

Hourly Rate/Salary:


May we contact?

Dates of Employment:

Hourly Rate/Salary:


May we contact?

Dates of Employment:

Hourly Rate/Salary:

Employment Requirements:

Office of the Inspector General: Have you ever been excluded from participation in Medicare, Medicaid and/or other State or Federal health care programs?
I-9/E-Verify Information: If emploment is pursued you will be required to produce original or certified documents and social security number verifying your identity and employment eligibility for reporting your earned wages. Are you able to provide verification of your identity within 3 days of hire?
Pre-Employment Criminal Background Check: Have you ever been convicted of a criminal offense by any court?
*Note: Conviction will Not necessarily disqualify you from employment consideration. The date, nature and circumstances will be considered in the relation of the position you are applying for.

If yes, was it a felony?

Attestation of Authenticity and Understanding:

Please read carefully and sign below: I verify that I have personally completed this application and the information reported in this application are true and correct to the best of my knowledge. I understand that any omission or misstatement of any information or documents related to my application and used to secure employment shall result in the rejection of my application or grounds for immediate discharge if I am employed, regardless of the time of discovery. I hereby authorize the Agency to thoroughly investigate my references, current and previous work record, education and training records and other subjects related to my suitability for employment. I also authorize my listed references and previous employers to disclose information to the Agency and waive and release the reported references and employers from any and all claims, demands, or liabilities arising out of or in any way related to what are disclosed.

When my 93-year-old father took ill two years ago, I turned to Cypress HomeCare for assistance. It was one of the wisest decisions I made during an extremely difficult time. They treated my dad — and me — like we were family.

– Bill, son of client

Call today for your free in-home care assessment (602) 264-8009