Pre-Screening Application

Contact Information

Full Name

Email Address

Phone Number

Full Address

Town/City

Check the appropriate box below:

 I am a New Applicant.

 I am a Current GSIL Employee. Select your objective below.
---I'm looking for more hours.I would like to be added to the GSIL Registry and have read the registry Rules & Regulations.I'm looking for more hours and to be added to the GSIL Registry.

 I am a Former GSIL Employee. When were you employed?

*I am interested in the following home care job openings:

Position Specific Information

Do you have any Personal Care experience?
 Yes No

Do you have any experience with Personal Care equipment?
 Yes No

Are you equally comfortable with male and female consumers?
 Yes No

Are you comfortable in a smoking environment?
 Yes No

Are you comfortable with pets, such as dogs and cats?
 Yes No

Do you have any lifting restrictions?
 Yes No

Criminal background checks and Bureau of Elderly and Adult Service checks will be performed on all applicants, per DHHS regulations. Will there be any findings on your background checks?
 Yes No

If a position requires driving, do you have 100/300 Liability on Auto Insurance?
 Yes No

How many hours are you looking for?

Which days of the week are you able to work? Check all that apply.
 Sunday Monday Tuesday Wednesday Thursday Friday Saturday

What hours would you be able to work? Check all that apply.
 Morning Afternoon Evening

Please list specific towns you are willing to drive to.

How did you learn about GSIL?
FacebookCraigslistFriend/FamilyGSIL WebsiteNewspaperOther

What is the best time to reach you?