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: Last Name: Address: Address Line 2: City: State:AlabamaAlaskaArizonaArkansasAmerican SamoaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code: Email: Mobile Phone: Home Phone: Match Criteria: Please select checkboxes that match your skills and preferences. General Dementia Experience Hospice Experience Incontinence Experience Insured Automobile Live-In Shifts OK OK with Client Smoking Transfers Gait Belt Experience Hoyer Lift Experience Pets OK with Cats OK with Dogs Max client weight for transfers: 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 Car Insurance Chest X-Ray CNA License Driver’s License CPR Certification HHA Certification Registered Nurse Passport Performance Evaluation State ID Card Tuberculosis Test LVN/LPN Certification Competency Exam Supervisory Visit VA New Hire Reporting Tuberculosis Questionaire I9 complete Sworn Affidavit Permanent Resident 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:AlabamaAlaskaArizonaArkansasAmerican SamoaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code: Date Employed: To: Employer: Supervisor: Phone Number: Address 1: Address 2: City: State:AlabamaAlaskaArizonaArkansasAmerican SamoaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code: Date Employed: To: Employer: Supervisor: Phone Number: Address 1: Address 2: City: State:AlabamaAlaskaArizonaArkansasAmerican SamoaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming 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 type of shifts are you willing to work? (Night shifts, Days, Live in?): How did you hear about Stay Well Home Health Care? Please type your name here as verification that the information provided in your application is correct.