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:

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
	5 year certificate
	Background Check
	Car Insurance
	Chest X-Ray
	Clinical Competency Evaluation (Skills)
	CNA License
	COVID-19 Vaccine
	CPR Certification
	Driver's License
	Driving Record Check
	Driving Record Follow-up
	Exit Interview Completed
	First Aid Certification
	Hep B Vaccination
	HHA Certification
	HR-PIP
	HR-Verbal Warning
	HR-Written Warning
	ID Badge
	Liability Insurance
	LVN/LPN Certification
	MMR Vaccination/Titer Test
	Orientation Completed
	Passport
	Performance Evaluation
	Permanent Resident Card
	Registered Nurse
	Scrub Top
	Sign on Bonus Alert
	State ID Card
	Tuberculosis Test
	Work Authorization Card
	Work Physical
	Yearly TB Questionnaire

+ 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:

How were you referred to Preferred Care at Home?

Do you accept the starting pay hourly rate of $19/hr or $190-200 per day live-in? This start rate is non-negotiable.

What days of the week are you available? Please select one or more from the following and be specific: Days, Evenings, Weekends, Live-in, Full-Time or Part-Time. What hours?

How many hours are you willing to work per week?

What date are you available to start working?

How many miles are you willing to travel to get to your client? :

At times, you may be required to use your own personal vehicle to transport clients or run errands for the client. Are you willing to use your own personal vehicle for such cases?

Do do you have a valid driver’s license? If yes, please provide Drivers License Number:

Are you a certified CHHA in NJ? Please include Certification Number, Issuing Authority, and Expiration Date (REQUIRED).

How many years of experience do you have? Have you worked for an agency before?

Have you had a Mantoux (PPD/TB) test within the last 12 months? If so, do you have proof of results (this is required prior to you being placed on case)? :

Have you had MMR (Measles/Mumps/Rubella) Vaccination (this is required prior to you being placed on case)?

Disclaimer:

I certify that the information I have given in this application for employment is correct to the best of my knowledge. I understand that falsifying information is grounds for rejection of my application or termination of my employment if I am hired. I authorize any person, organization, or company I have listed on this application to release any and all requested information regarding my previous employment.

Signature: