Please complete all required fields which are noted with a *.

Personal Data
*
            *
            *
*   
 

Yes    No
May we call you at work? *


Yes    No
If you are under 18 and it is required, can you furnish a work permit?


Yes    No
Have you ever submitted an application to us before? *


Yes    No
Are you legally eligible for employment in this country? *
*
*
Yes    No
Are you able to meet the attendance requirements of the position? *
Yes    No
Will you work overtime if required? *


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


Note: Answering "Yes" to these questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

Employment History

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

(Month/Year)      (Month/Year)
     
Yes   No   Later
May we contact for reference?

2. Employment Data

(Month/Year)      (Month/Year)
     
Yes   No   Later
May we contact for reference?

3. Employment Data

(Month/Year)      (Month/Year)
     
Yes   No   Later
May we contact for reference?

4. Employment Data

(Month/Year)      (Month/Year)
     
Yes   No   Later
May we contact for reference?

Summarize any training, skills, licenses, and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.

Educational Background

Please list any job related education that you have.

  Name & Location Years Compl. Graduated? Major/Degree
High School Yes No *
College Yes No
Other Yes No
References
    Name Phone # Years Known
1. *
2.
3.
Other Information & Agreement

Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve, National Guard or any other similarly protected status.

List any additional information that you would like us to consider.

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.