Attendant Application

Required Attendant Employment Application Form

Step 1 of 6

Applicant Information
Last Name*
First Name*
MI*
Suffix

(Jr., Sr., II, III)
Birth Name*

List full name.
Prior Names Used

If applicable. List first and last names.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
County*
Phone #*
Cell #*
Email Address*
Other Contact #
Parent
Friend
Other
Birth Date*
MM slash DD slash YYYY
Gender*
Social Security Number*
Other SSN Used?
Are you a citizen of the United States?*
- YES
- NO
If no, are you authorized to work in the U.S.?*
- YES
- NO
If not authorized to work in U.S., Stop here.
If yes, copy of work authorization must be submitted with this application.
Resident of Missouri for past 5 years?*
- YES
- NO
If no, list other state(s):

Education
High School*
High School Address*
Street Address City State ZIP Code
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
Did you graduate?*
- YES
- NO
Degree*
College
College Address
Street Address Address Line 2 City State ZIP Code
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Did you graduate?
- YES
- NO
Degree
Other Education
Other Address
Street Address Address Line 2 City State ZIP Code
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Did you graduate?
- YES
- NO
Degree

References
Please list three professional references
1. Full Name*
1. Relationship*
1. Company*
1. Phone*
1. Address*
Street Address City State ZIP Code
2. Full Name*
2. Relationship*
2. Company*
2. Phone*
2. Address*
Street Address City State ZIP Code
3. Full Name*
3. Relationship*
3. Company*
3. Phone*
3. Address*
Street Address City State ZIP Code

Previous Employment
List the most recent job first
1. Company
1. Phone
1. Address
Street Address Address Line 2 City State ZIP Code
1. Supervisor
1. Job Title/Responsibilities
1. From
MM slash DD slash YYYY
1. To
MM slash DD slash YYYY
1. Reason for Leaving
2. Company
2. Phone
2. Address
Street Address Address Line 2 City State ZIP Code
2. Supervisor
2. Job Title/Responsibilities
2. From
MM slash DD slash YYYY
2. To
MM slash DD slash YYYY
2. Reason for Leaving
3. Company
3. Phone
3. Address
Street Address Address Line 2 City State ZIP Code
3. Supervisor
3. Job Title/Responsibilities
3. From
MM slash DD slash YYYY
3. To
MM slash DD slash YYYY
3. Reason for Leaving

Criminal History
Failure to disclose criminal history is Class A misdemeanor
Do you have any criminal convictions, finds of guilt, pleas of guilty and pleas of nolo contendere except minor traffic offenses?*
- Yes
- No
If yes, explain:
Are you registered with the Family Care Safety Registry (FCSR) maintained by the MO department of Health and Senior Services (DHSS)?*
- Yes
- No
Have you ever been listed on MO DHSS' Employee Disqualification List (EDL)?*
- Yes
- No
If yes, explain
Have you ever been listed on US Department of Health and Human Services' List of Excluded Individuals and Entities (LEIE)?*
- Yes
- No
If yes, explain
Blue Skies Home Care LLC works primarily with two populations: persons with disabilities and seniors. Do you have experience, paid or unpaid, working with either or both of these populations? If so please describe your experience and duties (maximum of seven lines):*
Certification, Consent and Signature
Required Documents

Applicant must submit copies of the following documents prior to employment by Customer of Blue Skies Home Care LLC:
- Social Security Number Card
- Both sides of Driver's License
- Work Authorization(s)
- And/or Other requested documents at time of application
My signature below certifies that the answers I have given in this attendant application are true and complete to the best of my knowledge. Further I consent to a pre-employment criminal records check and a closed record check pursuant to Section 610.210 RSMo and periodic pre-employment and post-employment checks as required by state and federal regulations and laws, including but not limited to, E-Verify, HHS-OIG’s List of Excluded Individuals and Entities, DHSS’ Family Care Safety Registry, and DHSS’ Employee Disqualification List. Further I agree to immediately disclose to Blue Skies Home Care LLC any and all information regarding marital status and criminal history, current and future, and any inclusions on the above mentioned registries and lists. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release from employment. I understand that failure to provide required information to Blue Skies Home Care LLC may subject me to possible recoupment of payments.
Signature*
Date*
MM slash DD slash YYYY

Attendant Application

Required Attendant Employment Application Form

Step 1 of 6

Applicant Information

Other Contact #

If not authorized to work in U.S., Stop here.

If yes, copy of work authorization must be submitted with this application.

Education

References

Previous Employment

Criminal History

Certification, Consent and Signature

Required Documents

MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES FAMILY CARE SAFETY REGISTRY WORKER REGISTRATION

SOCIAL SECURITY NUMBER

PERSONAL INFORMATION

CONTACT INFORMATION

We want to help you get started with services as soon as possible. Give us a little bit of information about yourself and someone from our office will reach out within 1 business day.

Contact PopUp Form

We are excited you want to switch to Blue Skies! We want to help you get started with services as soon as possible. Give us a little bit of information about yourself and someone from our office will reach out within 1 business day.

Contact PopUp Form