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
	APS Check -5 YEAR
	Car Insurance
	Child Protective Service Check -5 YEAR
	CNA License
	Compliance Quiz -1 YEAR
	Criminal Background Check -5 YEAR
	Driver's License
	Maine Registry Check -1 YEAR
	NH - BAAS Check - 1 YEAR
	NH - Background Att. -1 YEAR
	Passport
	Performance Evaluation
	Permanent Resident Card
	RELIAS Training -1 YEAR
	State ID Card

+ 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?

What are your days and hours of availability?

Please list 1-2 Emergency Contacts:

Are you authorized to work in the United States?

Desired Start Date:

Are you willing and able to provide full personal care to male and female clients?

Can you work in homes where pets are present?

Disclaimer:

I confirm that the information provided in this application is accurate and complete. I understand that any false or misleading statements, or omissions, may result in the rejection of my application or termination of employment. I authorize the company to verify the information I have provided and to conduct any necessary background checks. I release all individuals and organizations involved from any liability for sharing or verifying this information.

Signature: