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:

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:

What position are you interested in? (Caregiver, Nurse, Lead On Call Caregiver, Support Specialist):

What is your Expected Wage per Hour?

When are you able to work? (Example: What days, hours, etc.):

Are you at least 18 years of age? :

If hired, can you provide proof of your legal eligibility to work in the United States? Please answer yes or no. If no, please explain. :

Do you currently have or have you ever held a certification in the healthcare field? (Ex: CNA, HHA, MA, LPN, RN, etc.)? If yes, please list certification(s).

Have you ever been convicted of a crime?

If employed, may we contact your current employer?

How did you hear about us?

Disclaimer:

Applicant Statement: By submitting this application I certify that all information provided is accurate, true and complete. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from employment, regardless of time discovered. I understand that any offer of employment is contingent on reference and background checks. I authorize, Kore Cares, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview and to conduct a criminal background check. I understand that Kore Cares does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and Kore Cares reserves the right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of Kore Cares is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing expressed language are valid. I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and the federal immigration laws require me to complete an I-9 Form.

Signature: