Caregiver Application | WellSky Personal Care

Applicant Information:

First Name*:

Middle Name*:

No Middle Name:

Preferred Name:

Last Name*:

Address*:

Address Line 2:

City*:

State*:

Postal Code*:

Home Phone:

Mobile Phone*:

Email*:

Location:

Hours wanted weekly*:

Date Of Birth:

Education & Training:

High School

College

School:

Degree received:

Certifications and Credentials:

Please check all that apply, and enter the expiration date and any notes as applicable.

Active	Type	Expiration Date	Notes
	Car Insurance
	Chest X-Ray
	CNA License
	CPR Certification
	Driver's License
	First Aid Certification
	HHA Certification
	LVN/LPN Certification
	Passport
	Performance Evaluation
	Registered Nurse
	State ID Card
	Tuberculosis Test

+ Add Additional Certification or Credential

Employment History:

Please provide your most recent positions of employment.

Employer:

Supervisor:

Phone Number:

Address 1:

Address 2:

City:

State:

Postal Code:

Date Employed:

To:

Employer:

Supervisor:

Phone Number:

Address 1:

Address 2:

City:

State:

Postal Code:

Date Employed:

To:

Employer:

Supervisor:

Phone Number:

Address 1:

Address 2:

City:

State:

Postal Code:

Date Employed:

To:

+ Add Additional Employer

Professional References:

Please provide professional references.

Name:

Phone Number:

Name:

Phone Number:

Name:

Phone Number:

+ Add Additional Reference

Additional Information:

List 3 words to describe you?

Shifts Availability? (Please be as specific as possible):

Are you available to work every other weekend? (Saturday and Sunday):

Are you available to work holidays?

How many years of senior care experience?

Desired hourly pay?

Have you been found guilty of a crime in the past 10 years? If yes, for what?

Why should we hire you?

How did you hear about us?

Disclaimer:

employment and any pertinent information they may have personal or otherwise, and release the company from all liability for any damage that from utilizing such information. I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative. I understand that a criminal records check and drug screening are necessary prior to my employment. I understand that, in compliance with federal law, the company will provide me with a written authorization form for me to consent to these reports/screenings. I also understand that a conviction or failed drug screening will not automatically result in disqualification of employment” This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disability Act (ADA) and other relevant federal and state laws. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification document form upon hire.

Signature:

Thank you for your interest in working for our agency.

Please submit the application below to be considered for a position as a caregiver.

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