Caregiver Application | WellSky Personal Care

Thank you for your interest in working for our agency.

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

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
	Alzheimers
	Assistance with Self Medication Administration
	Car Insurance
	Car Registration
	CNA License
	CPR Certification
	Cultural Competency
	Domestic Violence
	Driver's License
	Elder Abuse
	Free of Communicable Dz
	HHA Certificate
	HIPPA
	HIV
	Level II Background
	LVN/LPN Certification
	Permanent Resident Card
	Professional Liability Ins
	Registered Nurse
	State ID Card
	Work Permit

+ 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:

Are you a Citizen of the United States? Yes/No :

Are you authorized to work in the U.S.? Yes/No:

Have you ever been convicted of a felony? Yes/ No If Yes, Explain :

Do you have experience in Home Care? Yes/No. How many Years of Experience :

Are you a HHA/CNA/RN/LPN? :

(HHA's only) What is the name of the School you received your HHA Certificate from: :

Are you available to work weekends? Yes/ No :

Available to work Days? Yes/No Available to work Nights? Yes/No Hours available to work :

How many miles are you willing to travel for work?

Current/ Previous Employer.

Previous Employer :

May we contact your supervisor for a reference? Yes/No:

How did you hear about us.

Are you willing to live in? Yes/No:

Why are you looking for a job in Home Care?

Disclaimer:

I certify that the information entered in this application is correct to my knowledge. I understand that falsification of information is grounds not to contract me as an Independent Contractor or to terminate my contract if signed on.

Signature: