CAREGIVERS APPLICATION FORM

This form is to be completed and returned to the office of ANSMED HOME CARE. Fill this
form in BLOCK LETTERS.

• Kindly note that recruitment will be based on your professional competences only
• Calibre of professionals recruited include Individuals with certificate in health care
(Ward Assistant with NVTI certificate, Nursing Assistant Clinical, Nursing Assistant
Preventive, Registered Nurses - both Diploma and Degree and those with certification
in Home Care
• Kindly note that the applicant is solely responsible for providing us with accurate
information as may be requested on the form.
• As part of our application process, a background check may be carried out on you.
• Selected applicants will be called for interview (this may include written exams) and
those who successfully go through shall be arranged for orientation.
• You will have to fill the Rules of Engagements (request for a copy after filling) and
staff form after orientation.
• Medical screening will be done for you before you go for your first assignment.
• An amount of GHC150.00 will be deducted from source as a fee for your application
process during your first payment from AnsMed Home Care Ltd.
• By continuing to partake in the application process, you agree to all the Terms and
Conditions of AnsMed Home Care Limited regarding recruitment and or
employment.

Page 1 of 8 Application Form

 CAREGIVERS APPLICATION FORM
PERSONAL PARTICULARS:

a) Surname: ……………………………………………………………………………………
b) First Names: ………………………………………………………………………………..
c) Other Names: ……………………………………………………………………………….
d) Present Residential Address (Location – include nearest landmark): …......………………
………………………………………………………………………………………………
...............................................................................................................................................
e) City or Town Residential Address Is: ...................................................................................
f) District Residential Address Is: ............................................................................................
g) Region Residential Address Is: .............................................................................................
h) Ghana Post Digital Address: …………………………………………………………….
i) Telephone Numbers……………………/………………………/………………………….
j) Email: ………………………………………………………………………………………
k) Date of Birth……………………………..Place of Birth………………………….……….
l) Nationality: …………………………… Home Town: …………………………………….
m) Are you single or married? …………………………………………………………………
If Married, Name of spouse ……………......……………………………………………….
n) Religious Affiliation: ……………………………………………………………………….
o) Branch Name of Religious Affiliation & Location: ………………………………………
..............................................................................................................................................
p) Next of Kin: .........................................................................................................................
Contact Number of Next of Kin: ………………………………………………………….
Relationship to Next of Kin: .................................................................................................
q) Kindly provide us with your details as it may appear on the following social media
handles
a. Facebook Profile Name: …………………………………………………………
b. Twitter Profile Name: ……………………………………………………………
c. WhatsApp Number: ………………………………………………………………
d. Instagram Profile Name: …………………………………………………………
e. Telegram Number: ……………………………………………………………….

Page 2 of 8 Application Form

 CAREGIVERS APPLICATION FORM
1. EDUCATION AND TRAINING

Type of Name Location Year Year

School Commenced Completed
Primary

Junior
Secondary /
High
Senior
Secondary /
High
Tertiary 1

Tertiary 2

2. EMPLOYMENT HISTORY

Dates Name and Address of Employer Position Held Salary

From To

Page 3 of 8 Application Form

 CAREGIVERS APPLICATION FORM
3. Qualifications or Certificates

Type of Name of Institution Type or Name of Certificate Date

School awarding certificate Certificate Number obtained
Junior
Secondary /
High
Senior
Secondary /
High
Tertiary

Professional
Certificate

PIN

Other
Certificate

Other
Certificate

4. TWO REFEREES

Name of Referee Phone Email Address Institution to Position of Relationship

Numbers of of Referee find Referee Referee to Referee
Referee

Page 4 of 8 Application Form

 CAREGIVERS APPLICATION FORM
5. CERTIFICATION (Two witnesses required)
a) WITNESS (Could be a Pastor, Headmaster, Civil Servant etc but not your relative)

I ............................................................................................................ (Name of Witness),

…………………………………………………………………... (Position of Witness) of
………………………………………………………. (Institution Witness can be Found)
do hereby certify that, the information given by
….………………….……………………………………………… (Name of Applicant)
on this form is correct. I also attest that the applicant is a well-behaved person who will
comport himself or herself in all ramifications if given the opportunity to work and thus,
should be considered for a home care employment. By signing this document, I agree to
bear full responsibility of his/her conduct whiles at post.

a) Present Residential Address:

………………………………………………………………………………………………
………………………………………………………………………………………………
b) Ghana Post Digital Address:
………………………………………………………………………………………………
c) Telephone Numbers
………………………………/……………………………/………………………………..
d) Email:
………………………………………………………………………………………………
e) Relationship to Applicant:
………………………………………………………………………………………………
f) Kindly attach coloured photocopy of any current National ID of the Witness – both
front and back.

……………………………….. ……………………………………
Date Signature & Stamp of Witness

Page 5 of 8 Application Form

 CAREGIVERS APPLICATION FORM
b) WITNESS (Must be a relative)

I ............................................................................................................ (Name of Witness),

…………………………………………………………………... (Position of Witness) of
………………………………………………………. (Institution Witness can be Found)
do hereby certify that, the information given by
….………………….……………………………………………… (Name of Applicant)
on this form is correct. I also attest that the applicant is a well behaved person who will
comport himself or herself in all ramifications if given the opportunity to work and thus,
should be considered for a home care employment. By signing this document, I agree to
bear full responsibility of his/her conduct whiles at post.

g) Present Residential Address:

………………………………………………………………………………………………
………………………………………………………………………………………………
h) Ghana Post Digital Address:
………………………………………………………………………………………………
i) Telephone Numbers
………………………………/……………………………/………………………………..
j) Email:
………………………………………………………………………………………………
k) Relationship to Applicant:
………………………………………………………………………………………………
l) Kindly attach coloured photocopy of any current National ID of the Witness – both
front and back

……………………………….. ……………………………………
Date Signature & Stamp of Witness

Page 6 of 8 Application Form

 CAREGIVERS APPLICATION FORM

6. Original copies of the following documents must be submitted to be

scanned
i. ECG Bill or Payment Slip (Prepaid or Post-paid is accepted)
ii. Certificates – JHS, SHS, Tertiary, Professional
iii. PIN/AIN
iv. Voter’s ID card/Passport/ Driving license/Ghana Card
v. One passport size picture

Also note that,

vi. You must draw a Directional map from AnsMed office to your house, that is if you
reside in Accra. If not a resident of Accra, a directional map should be drawn from a
major landmark such as Police Station, Post Office, or Government School to your
house.

7. APPLICANT

I certify that the information given on this form is correct and all the attached documents
are my certified true copies.

Name of Applicant: .........................................................................................................

Signature of Applicant: ...................................................................................................

Date: ................................................................................................................................

Page 7 of 8 Application Form

 CAREGIVERS APPLICATION FORM
Draw Directional Map to House Here

Page 8 of 8 Application Form