WisCaregiver CNA Program Employer Registration Form

Page 1

Application Type

Nursing Home Name

Nursing Home Address Line 1

Nursing Home Address Line 2

Nursing Home City

State

Postal Code

Primary Contact Information

CNA training/Supervisor Contact First Name

CNA training/Supervisor Contact Last Name

CNA training/Supervisor Contact Title

CNA training/Supervisor Contact Phone Number

CNA training/Supervisor Contact Email Address

Additional Contact Information

Accounts Receivable Contact Person (first and last name)

Accounts Receivable Contact Person Title

Accounts Receivable Contact Person Phone Number

Accounts Receivable Contact E-mail Address

Recruiting/HR Contact Name

Recruiting/HR Contact Title

Recruiting/HR Contact Phone Number

Recruiting/HR Contact E-mail Address

Do you know who your facility's TMU contact is?

YesNo

TMU Contact First Name

TMU Contact Last Name

TMU Contact Title

TMU Contact Phone

TMU Contact Email

Postal Code

What type of entity/provider are you?

Skilled Nursing Facility Other

If you selected other - please provide us with what type of entity/provider your facility is

Please enter the main webpage/home page URL for your facility

URL Web Address for CNA TRAINEE Job Posting

Registrants are required to check the three boxes below:

WisCaregiver Employers agree to not seek Medicaid reimbursement for CNA training in addition to the WisCaregiver Careers reimbursement. Collecting both kinds of reimbursement is considered Medicaid fraud.

I understand

WisCaregiver Careers will reimburse employers' training for those who attain certification at a flat rate of $700.WisCaregiver Careers will provide $300.00 employer success bonus at this time.

I agree

WisCaregiver Employers agree to hire WisCaregivers as CNA trainees and then to coordinate and pay for their CNA training upfront. Upon 6-month retention, Employers will receive $500 retention bonuses and agrees to pay the $500.00 to the employee.

I agree