Wellspring Home Care

APPLICATION FOR EMPLOYMENT

Application for Employment

All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin, or handicap. All information provided herein will be kept confidential.

PERSONAL INFORMATION

Name *

First Name

Last Name

Date *

Address *

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Home Phone Number *

Social Security Number *

Driver's License / ID *

State (License)

Date of Birth *

Email Address

Have you ever applied for employment with this Agency?

Yes No

How many hours a week are you available for work?

Are you legally eligible for employment in the United States?

Yes No

Are you willing to work:

Evenings Weekends

Position applying for:

Educational Background

Name of University

City/State

Degree

Did you graduate?

Yes No

Name of Vocational College

City State

Course of Study

Did you graduate?

Yes No

Name of High School

City/State

Did you graduate?

Yes No

Other - List any other degrees or certificate of study earned you would like to share.

EMPLOYMENT

List the last five years employment history, starting with the most recent employer.

1. Company Name

Telephone

Address

Start Date

End of Employment

Starting Pay

Ending Pay

Job Title and Describe Work Completed

Reason for leaving

2. Company Name

Telephone

Address

Start Date

End of Employment

Starting Pay

Ending Pay

Job Title and Describe Work Completed

Reason for leaving

3. Company Name

Telephone

Address

Start Date

End of Employment

Starting Pay

Ending Pay

Job Title and Describe Work Completed

Reason for leaving

Was your last name different from your present name during the above listed jobs?

Yes No

If yes, what was your name?

Are you currently employed?

Yes No

TWO (2) Professional / Personal Reference Check

1. Full Name *

Phone *

Address *

State

Professional Reference: Position Held

2. Full Name *

Phone *

Address *

State

Professional Reference: Position Held

GENERAL

Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

Yes No

Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full:

If you answered No, which job requirement can you not meet?

CREDENTIALS / SPECIALIZED SKILLS & QUALIFICATIONS

Credentials / Specialized Skills & Qualifications

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.

I authorize complete investigation of all statements contained herein and hereby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that may result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time shall inquire as to whether or not applications are being accepted at that time.

Print Full Name *

Signature *

Date *

Wellspring Home Care

Employee Emergency Contact Form

Employee Information

First Name *

Last Name *

Phone Number *

Email *

Signature *

#1 - Emergency Contact

Contact #1 - First Name *

Contact #1 - Last Name *

Contact #1 - Phone Number *

Contact #1 - Email

Contact #1 - Relationship to Employee *

#2 - Emergency Contact

Contact #2 - First Name

Contact #2 - Last Name

Contact #2 - Phone Number

Contact #2 - Email

Contact #2 - Relationship to Employee

Medical Information

Physician First Name

Physician Last Name

Physician Phone Number

Preferred Hospital

Wellspring Home Care

UPLOADS

First Name *

Last Name *

UPLOAD DRIVER'S LICENSE or STATE ID

DL # or State ID #

Upload Front of DL License or State ID

Upload Back of DL License or State ID

UPLOAD SOCIAL SECURITY CARD

Upload FRONT of SS Card

Upload BACK of SS Card

UPLOAD PROFESSIONAL LICENSE

Upload FRONT of License

CPR CARD

Upload FRONT of CPR Card

UPLOAD SOCIAL SECURITY CARD

Upload FRONT of Social Security Card

Signature *

Date *

Pre - Hire Forms

PRE-HIRE FORMS

APPLICATION FOR EMPLOYMENT

Application for Employment

PERSONAL INFORMATION

Educational Background

EMPLOYMENT

TWO (2) Professional / Personal Reference Check

GENERAL

CREDENTIALS / SPECIALIZED SKILLS & QUALIFICATIONS

Employee Emergency Contact Form

Employee Information

#1 - Emergency Contact

#2 - Emergency Contact

Medical Information

UPLOADS

UPLOAD DRIVER'S LICENSE or STATE ID

UPLOAD SOCIAL SECURITY CARD

UPLOAD PROFESSIONAL LICENSE

CPR CARD

UPLOAD SOCIAL SECURITY CARD