Caregiver Application | WellSky Personal Care

Applicant Information:

First Name*:

Middle Name*:

No Middle Name:

Preferred Name:

Last Name*:

Address*:

Address Line 2:

City*:

Province*:

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
	Access to reliable car
	Car Insurance
	Clear Background Check
	CPR Certification
	Driver's License
	First Aid Certification
	HHA Certification
	Law 90
	LVN/LPN Certification
	PAB Certification
	PDSB Certification
	Performance Evaluation
	Registered Nurse
	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:

Province:

Postal Code:

Date Employed:

To:

Employer:

Supervisor:

Phone Number:

Address 1:

Address 2:

City:

Province:

Postal Code:

Date Employed:

To:

Employer:

Supervisor:

Phone Number:

Address 1:

Address 2:

City:

Province:

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:

Were you referred by someone? If so, who?

Do you have any caregiving experience? Please explain. :

Are you willing to work off the island of Montreal? e.g West Island, South Shore and Laval. :

Are you able to work days? :

Are you able to work evenings? :

Are you able to work nights? :

Are you able to work weekends (Saturday and/or Sunday)? :

When are you available to start work? Please answer: Immediately, within the month or within three months.

Do you have a car?

Disclaimer:

En cliquant sur le bouton "Soumettre", j'autorise Helpers Care (9275-2609 Quebec Inc.) à procéder à une vérification de mes antécédents et à des enquêtes pour vérifier ma formation, mes antécédents professionnels, mes références et d'autres informations nécessaires. Je permets à ces personnes de divulguer des renseignements sur mon emploi, y compris la nature, la durée, la qualité de mon rendement et ma conduite. Je déclare que toutes les informations contenues dans ma candidature et/ou mon curriculum vitae sont exactes et précises. Je comprends qu'une fausse déclaration ou l'omission de faits pertinents peut m'exclure de l'emploi chez Helpers Care ou entraîner mon licenciement. J'ai lu et compris les informations ci-dessus. /// By clicking the "Submit" button, I authorize Helpers Care (9275-2609 Quebec Inc.) to conduct a background check and inquiries to verify my education, work history, references and other necessary information. I allow these individuals to disclose information about my employment, including the nature, duration, quality of my performance, and conduct. I declare that all the information on my application and/or curriculum vitae is true and accurate. I understand that a false statement or an omission of pertinent facts may disqualify me from employment with Helpers Care or result in my dismissal. I have read and understood the information above.

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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