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
	CNA License
	CPR Certification
	Driver's License
	First Aid Certification
	HHA Certification
	LVN/LPN Certification
	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 ANY OTHER NAMES USED OR WORKED UNDER:

ARE YOU LEGALLY AUTHORIZED TO WORK IN THE US?

EMERGENCY CONTACT: NAME / CONTACT NUMBER:

HAVE YOU EVER BEEN CONVICTED OF, PLEAD GUILTY/NO CONTEST TO, OR HAD A SUSPENDED IMPOSITION OF SENTENCE FOR ANY OFFENSE (OTHER THAN A MINOR TRAFFIC VIOLATION)? YES / NO:

IF YES, EXPLAIN: (A convictional record will not necessarily exclude you from consideration. This information will be used only for job-related purposes and only to the extent permitted by law).

HAVE YOU EVER SERVED IN THE U.S. ARMED FORCES: YES / NO, BRANCH OF SERVICE, RANK, DISCHARGE DATE:

LIST JOB TITLE, RATE AND REASON FOR LEAVING YOUR FIRST LISTED EMPLOYER:

LIST JOB TITLE, RATE AND REASON FOR LEAVING YOUR SECOND LISTED EMPLOYER:

LIST JOB TITLE, RATE AND REASON FOR LEAVING YOUR THIRD LISTED EMPLOYER:

ARE YOU 18 YEARS OR OLDER?

LIST JOB TITLE, RATE AND REASON FOR LEAVING YOUR FOURTH LISTED EMPLOYER:

Disclaimer:

I certify that the information contained in this application is correct to the best of my knowledge. I understand that to falsify information is grounds for refusing to hire me, or for discharge should I be hired. I authorize any person, organization or company listed on this application to furnish you any and all information concerning my previous employment, education and qualifications for employment. I also authorize you to request and receive such information. In consideration for my employment, I agree to abide by the rules and regulations of the company, which rules may be changed, withdrawn, added or interpreted at any time, at the company's sole option and without prior notice to me. I also acknowledge that my employment may be terminated, or any offer or acceptance of employment withdrawn, at any time, with or without cause, and with or without prior notice at the option of the company or myself.

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.

General

Transfers

Pets