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
	Background Check
	Car Insurance
	Chest X-Ray
	CNA License
	Competency Exams
	CPR Certification
	DMV Check
	Driver's License
	Drug Screen
	First Aid Certification
	Flu Vaccination
	HCA Registry
	HHA Certification
	Learning Center Courses
	LVN/LPN Certification
	Passport
	Performance Evaluation
	Physical Exam
	Registered Nurse
	State ID Card
	TB Screen Form
	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:

Are you 18 years of age or older?

If hired, can you provide proof of legal age?

If hired, will you be able to furnish proof of your legal right to work in the United States?

Have you ever worked or attended school under another name?

If yes, Name:

Do you have reliable transportation?

Hourly requirement?

Are you available to work Full time or Part time? :

Hours and days you are available? :

Date you can start?

Were you previously employed by Interim HealthCare? If yes, when?

Have you previously filled an application with us? If yes, when?

How did you learn of Interim HealthCare?

If you are selected for an offer, Interim requires background screening as part of our hiring process in accordance with all applicable laws. Bonding is a condition of employment. Have you ever been denied such a bond or is such a bond has been issued to cover you has it been qualified and or canceled. Please answer yes or no? :

Are you a licensed professional? If yes what is the classification? RN, LP/LVN or Other? What is the License number and Renewal number?

Has your license ever been suspended or revoked? If yes, please explain:

Many of the positions which Interim HealthCare has available require, as essential job functions, that the employee lift, turn or move patients/clients or medical equipment. These positions may also require, as essential job functions, that the employee assist a patient/client in turning, standing, walking or sitting. If you accept a position that requires the employee to perform these essential job functions, can you perform them with or without accommodations? Please answer yes or no? :

Disclaimer:

Equal Employment opportunity Policy: It is the policy and practice of the company to abide by all anti-discrimination laws provided by federal, state, and local statutes and regulations. It is also the policy and practice of the company to provide and promote equal employment opportunities for all applicants and employees It is also the policy and practice of the company to hire, train, promote, compensate, and administer all employment practices without regard to race, color, religion, sex, national origin, age, marital status, medical condition, veteran status, sexual orientation, disability unrelated to the ability to perform the essential functions of a job, or any other protected status. Furthermore, the company is committed to complying with the Americans With Disabilities Act. If you believe that you need a reasonable accommodation in order to apply for or to complete an application for employment due to the fact that you have a disability we request that you notify the company of your specific needs for a reasonable accommodation so that the company can assist you where appropriate. In order that your application may be properly evaluated, it is essential that ALL of the following questions be answered carefully and completely. If you need more space for your answers, please attach a separate sheet. Feel free to add any additional information which will help us in placing you where you are best qualified.

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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