Position(s) Applied For*

Referral Source

Advertisement Employment Relative Web Site Private Employment Agency Government Agency Other

Name of Source (if applicable)

First Name*

M

Last Name*

Address*

City*

State*

Zip*

Phone*

Mobile/Beeper/Other #

If necessary, best time to call you at home is

May we call you at work?*

Yes No

If yes, work number and best time to call

If you are under 18 and it is required, can you furnish a work permit?

Yes No

If so, please explain

Have you ever submitted an application to us before?*

Yes No

If yes, give date(s) and position(s) applied for

Are you legally eligible for employment in this country?*

Yes No

Date Available for Work*

Desired salary range?

Type of employment desired*

Full-Time Part-Time Temporary Seasonal Educational Co-Op

Are you able to meet the attendance requirements of the position?*

Yes No

Will you work overtime if required?*

Yes No

If no, please explain

Have you ever pled "guilty" or "no contest" to, or been convicted of a crime?*

Yes No

If yes, please provide date(s) and details

If you are applying for a position with Personal Care Services, are you a Certifiied Nursing Assistant?

Yes No

Provide the following information of your past and current employers, assignments or volunteer activities, starting with the most recent. Explain any gaps in employment in the comment section at the end of the application.

1. Employment Data

From Date (Month/Year)

To Date (Month/Year)

Name

Address

Phone #

Immediate Supervisor

Type of work and job responsibility

Reason for Leaving

Salary Start

Salary Finish

May we contact for reference?

Yes No Later

2. Employment Data

From Date (Month/Year)

To Date (Month/Year)

Name

Address

Phone #

Immediate Supervisor

Type of work and job responsibility

Reason for Leaving

Salary Start

Salary Finish

May we contact for reference?

Yes No Later

3. Employment Data

From Date (Month/Year)

To Date (Month/Year)

Name

Address

Phone #

Immediate Supervisor

Type of work and job responsibility

Reason for Leaving

Salary Start

Salary Finish

May we contact for reference?

Yes No Later

4. Employment Data

From Date (Month/Year)

To Date (Month/Year)

Name

Address

Phone #

Immediate Supervisor

Type of work and job responsibility

Reason for Leaving

Salary Start

Salary Finish

May we contact for reference?

Yes No Later

Skills and Qualifications

Please list any job related education that you have.

High School

Name & Location

Years Completed

Graduated?

Yes No

Major/Degree*

College

Name & Location

Years Completed

Graduated?

Yes No

Major/Degree

Other

Name & Location

Years Completed

Graduated?

Yes No

Major/Degree

1. Name

Phone #

Years Known*

2. Name

Phone #

Years Known

3. Name

Phone #

Years Known

Special accomplishments, publications, awards, etc.

Comments

Please read carefully before submitting:
I understand that if I am employed, any misrepresentation of material omission made by me on this application will be sufficient cause for cancellation of this application or immediate discharge from the employer's service, whenever it is discovered. I give Well•Spring the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information contained in this application. I hereby release from liability the employer and its representatives for seeking, gathering and using such information and all other persons, corporations, or organizations for furnishing such information. The Employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by local, state or federal law. This application is current for only 60 days. At the conclusion of this time, if I have not heard from Well•Spring and still wish to be considered for employment, it will be necessary to complete a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and Well•Spring reserves the right to terminate my employment at any time, with or without cause and without prior notice, except as it may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no representative of Well•Spring other than an authorized officer has the authority to make any assurances to the contrary. I further understand that any such assurances must be in writing and signed by an authorized officer. I understand that it is Well•Spring's policy not to refuse to hire a qualified individual with a disability because of that person's need for a reasonable accommodation as required by the ADA. I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization. Finally, I understand that if I am hired, North Carolina law requires a criminal background check on all employees employed by a health care provider within five days of starting employment at Well•Spring. I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.

I represent and warrant that I have read and fully understand the foregoing and seek employment under these conditions.*