Submit An Application

Thank you for your interest in becoming part of the Wellness Care team. Wellness Care Nurse Registry Inc. provides our community with excellent service and commitment to caring. Please fill out this form to apply for caregiver jobs.

Care Givers Application

Last Name

First Name

Social Security Number

Street Address

City

State

Zip Code

Contact Phone

Alternate Number

Emergency Contact Name

Emergency Phone

Relationship

Driver's License

Yes

CPR Certified

Yes

Height

Credentials

Which position are you applying for?

Level of Credentialing

Companion

HHA

CNA

LPN

Availability

Preferred Start Date

Preferred Times

Mornings

Afternoons

Evenings

Nights

How many miles will you travel for an assignment?

Driving History

As part of the background screening process, a check of your driving record may be requested by a family seeking your services. Failure to disclose tickets or an accident will cause your application to be immediately rejected. (optional)

Vehicle Year, Make, Model, Color

(optional)

DUI Within Last 3 years?

Reckless Driving ticket within last 3 years?

Moving Violations within last 3 years?

Accidents in last 3 years?

If yes to any of the above, please explain (optional)

Ability to Transfer (optional)

Do you have any physical limitations (injuries etc.) that would prevent you from providing home care duties?

Can you stoop bend and lift up to 25lbs?

If yes to any of the above, please explain (optional)

Employment History

Please supply the requested information below for your previous 3 employers. Inaccurate information (example: wrong phone number) will delay the processing of your application. Please notify your work references that a Wellness Care Nurse Registry representative will be contacting them. (optional)

Employer Name

Employer Phone Number

Employer City

Employer State

Approximate Start Date

Supervisor Name

Reason for leaving?

If employed and under age of 18, can you furnish a work permit?

Yes

If hired, will you furnish proof you are eligible to work in the U.S.?

Yes

Have you ever been employed by Wellness Care Nursing?

Yes

when? From:

Have you worked or attended school under any other name?

Yes

If YES, give name

Have you ever been convicted of a crime and/or released from confinement following a conviction for any criminal offense?

Yes

Arrest or charges that have been expunged need not be disclosed. If YES, give date, place and nature of each such conviction.

Have you ever been fired from a job or asked to resign?

Yes

If YES, please explain

Are you presently charged with any violation of the law?

Yes

If YES, give date, place and nature of each such charge.

References

References to back up your capabilities as a professional (optional)

Please list up to three references that have personal knowledge of you and your character. Do not use anyone used in the Professional Reference section. Inaccurate information (example: wrong phone number) will delay the processing of your application. Please notify your personal references that a Wellness Care Nurse Registry representative will be contacting them.

Reference Name

Reference Phone Number

Reference Relationship

Reference Name

Reference Phone Number

Reference Relationship

Resume

Upload Resume

Upload your resume here

Uploading… (0%)

This is invalid

This file size is too big

APPLICATION AGREEMENT (Application not valid unless signed) (optional)

AFFIDAVIT: All answers given by me on this application and other pre-employment forms are true and correct. I agree that Wellness Care Nurse Registry shall not be liable in any respect if my contract is terminated because of falsifications, misstatements or omissions made by me. I authorize Wellness Care Nurse Registry and/or its representatives to conduct a thorough investigation of my background including; all previous employers, educational institutions and persons named in my application for employment, as well as government agencies, law enforcement agencies, licensing boards and any other persons who may have any information concerning my background, character, and qualifications. I release all parties from all liability for damages of whatever kind, which may be a result of this investigation.

This application will remain active no more than 90 days from the date it was made. I have read, understand, and by my signature agree and consent to these statements. I also agree that my typed name below will be as valid as a handwritten signature to the extent allowed by local law.

Applicant Signature