www.vitalialiving.net Open in urlscan Pro
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1 forms found in the DOM

POST /careers/submit.php

<form action="/careers/submit.php" method="post" accept-charset="utf-8" autocomplete="on">
  <div class="field-list clear">
    <fieldset id="1" class="form-item fields name required">
      <div class="title">Name <span class="required" style="color:red">*</span></div>
      <div class="field first-name">
        <label class="caption">
          <input class="field-element field-control" type="text" id="first" name="1" required=""> First</label>
      </div>
      <div class="field last-name">
        <label class="caption">
          <input class="field-element field-control" type="text" id="last" name="2" required=""> Last</label>
      </div>
    </fieldset>
    <fieldset id="2" class="form-item fields name required">
      <div class="field address" style="text-align: left;">
        <label class="caption-title">Address <span class="required" style="color:red">*</span></label>
        <input class="field-element field-control" type="text" id="Address" name="3" required="">
      </div>
      <div class="field apt" style="text-align: left;">
        <label class="caption-title">Apt # <span class="required" style="color:red">*</span></label>
        <input class="field-element field-control" type="text" placeholder="Enter none if not applicable" id="Apt #" name="4" required="">
      </div>
    </fieldset>
    <fieldset id="3" class="form-item fields name required">
      <div class="field city" style="text-align: left;">
        <label class="caption-title">City <span class="required" style="color:red">*</span></label>
        <input class="field-element field-control" type="text" id="city" name="5" required="">
      </div>
      <div class="field state" style="text-align: left;">
        <label class="caption-title">State <span class="required" style="color:red">*</span></label>
        <input class="field-element field-control" type="text" id="state" name="6" required="">
      </div>
    </fieldset>
    <fieldset id="4" class="form-item fields name required">
      <div class="field zipcode" style="text-align: left;">
        <label class="caption-title">Zip Code <span class="required" style="color:red">*</span></label>
        <input class="field-element field-control" type="text" id="zipcode" name="7" required="">
      </div>
      <div class="field email" style="text-align: left;">
        <label class="title">Email <span class="required" style="color:red">*</span></label>
        <input class="field-element" type="email" id="email" name="8" autocomplete="email" required="">
      </div>
    </fieldset>
    <fieldset id="5" class="form-item fields name required">
      <div class="field cell-phone" style="text-align: left;">
        <label class="caption-title">Cell Phone <span class="required" style="color:red">*</span></label>
        <input class="field-element field-control" type="text" id="cell" name="9" required="">
      </div>
      <div class="field home-phone" style="text-align: left;">
        <label class="caption-title">Home Phone <span class="required" style="color:red">*</span></label>
        <input class="field-element field-control" type="text" id="home" name="10" required="">
      </div>
    </fieldset>
    <div id="Date of Birth" class="form-item field name required">
      <label class="title">Date of Birth <span class="required" style="color:red">*</span></label>
      <input class="field-element" type="date" id="dob" name="11" required="">
    </div>
    <div id="Gender" class="form-item field name required">
      <label class="title">Gender <span class="required" style="color:red">*</span></label>
      <select id="gender" name="12" style="padding:10px;width:100%" required="">
        <option value=""> - Select - </option>
        <option value="Female"> Female </option>
        <option value="Male"> Male </option>
      </select>
    </div>
    <div id="Bank Name" class="form-item field name required">
      <label class="title">Bank Name <span class="required" style="color:red">*</span></label>
      <input class="field-element" type="text" placeholder="Enter the name of your bank for direct deposit validation" id="bankname" name="13" required="">
    </div>
    <fieldset id="Pay Per Hour" class="form-item fields name required">
      <div class="field pay-per-hour" style="text-align: left;">
        <label class="caption-title">Desired Pay Per Hour <span class="required" style="color:red">*</span></label>
        <input class="field-element field-control" type="text" id="payperhour" name="14" required="">
      </div>
      <div class="field employment" style="text-align: left;">
        <label class="title">Desired Employment <span class="required" style="color:red">*</span></label>
        <select id="employment" name="15" style="padding:10px;width:100%" required="">
          <option value=""> - Select - </option>
          <option value="Part-time"> Part-time (24 hours/Week) </option>
          <option value="Full-time"> Full-time (40 hours/Week) </option>
        </select>
      </div>
    </fieldset>
    <div id="Highest Education Level" class="form-item field name required">
      <label class="title">Highest Education Level <span class="required" style="color:red">*</span></label>
      <input class="field-element" type="text" id="highesteducationlevel" name="16" required="">
    </div>
    <div id="CPR Certification" class="form-item field name required">
      <label class="title">CPR Certification <span class="required" style="color:red">*</span></label>
      <select id="CPR-Certification" name="17" style="padding:10px;width:100%" required="">
        <option value=""> - Select - </option>
        <option value="Yes CPR"> Yes </option>
        <option value="No CPR"> No </option>
      </select>
    </div>
    <br>
    <div class="form-button-wrapper form-button-wrapper--align-center">
      <input class="button sqs-system-button sqs-editable-button" type="submit" value="Submit">
    </div>
  </div>
</form>

Text Content

VITALIA LIVING


POSITION: CAREGIVER | PAY PER HOUR: $25 - $30

Responsibilities:

Communicating with doctors. Companionship. Monitoring medications. Mobility
assistance. Transportation.

Qualifications:

A valid Driver's License or State ID. Ability to assist with ADLs. Able to work
flexible hours including overnights and weekends. CPR certification is optional.
We provide training.

Name *
First
Last
Address *
Apt # *
City *
State *
Zip Code *
Email *
Cell Phone *
Home Phone *
Date of Birth *
Gender * - Select - Female Male
Bank Name *
Desired Pay Per Hour *
Desired Employment * - Select - Part-time (24 hours/Week) Full-time (40
hours/Week)
Highest Education Level *
CPR Certification * - Select - Yes No