New Application » Wellsprings Post Acute Center

Today's Date:
Social Security Number:

This is not a secured form.
Telephone Number:
PERSONAL INFORMATION
Federal and State laws prohibit discrimination in employment because of sex, age, race, color, religious creed, marital status, national origin, ancestry, or handicap. The following must be accurate and complete and filled out by the applicant. Any false answers or information will be sufficient cause for rejection of the application or dismissal of the applicant if employed. Wellsprings Post Acute Center is an equal opportunity employer.
Last*
First*
Middle
Permanent Address*
City*
State*
Zip*
How long in this city?
Can you submit proof of age?
In an emergency, please notify:

Name, address, phone, and relation.

EMPLOYMENT RECORD
Give past 5 years or longer. Begin with your most recent employer. Must fill out completely. List all jobs, military service, and self-employment.
Job 1
Name of Employer Duties and Title Started Work (Month/Year) Left Work (Month/Year)
Job 1
Address of Employer (include zip code) Reason for Leaving
Job 1
Telephone Number (area code first) Your Supervisor May we Contact (Y or N) Rate of Pay
Job 2
Name of Employer Duties and Title Started Work (Month/Year) Left Work (Month/Year)
Job 2
Address of Employer (include zip code) Reason for Leaving
Job 2
Telephone Number (area code first) Your Supervisor May we Contact (Y or N) Rate of Pay
Job 3
Name of Employer Duties and Title Started Work (Month/Year) Left Work (Month/Year)
Job 3
Address of Employer (include zip code) Reason for Leaving
Job 3
Telephone Number (area code first) Your Supervisor May we Contact (Y or N) Rate of Pay
Job 4
Name of Employer Duties and Title Started Work (Month/Year) Left Work (Month/Year)
Job 4
Address of Employer (include zip code) Reason for Leaving
Job 4
Telephone Number (area code first) Your Supervisor May we Contact (Y or N) Rate of Pay
Job 5
Name of Employer Duties and Title Started Work (Month/Year) Left Work (Month/Year)
Job 5
Address of Employer (include zip code) Reason for Leaving
Job 5
Telephone Number (area code first) Your Supervisor May we Contact (Y or N) Rate of Pay
Personal References
Two required. DO NOT give relatives, present or past employers.
Name of Reference
Phone Number
Occupation
Where Employed
Name of Reference
Phone Number
Occupation
Where Employed
Unemployment History
Please account for any time(s) you were not employed in the last five years. You don't need to include periods of one month or less. You must account for all periods of unemployment.
Time Period
Reason(s) Unemployed
Time Period
Reason(s) Unemployed
NOTICE TO APPLICANT
The furnishing of former employers names is considered as your permission for us to contact them to verify the above information. Completion of the application is also considered as your consent to take any pre-employment and such future physical examinations as may be required by us and also indicates your willingness to comply with the work rules and regulations of the facility.
Signature of Applicant

By typing your name, this counts as your legal signature.
ONLY Professional and Technical applicants are to complete this section.
Are you registered or licensed in the United States and /or the State of California?
- Yes
- No
Fill out all applicable fields
Certification No. Date Am eligible
Fill out all applicable fields
License No. Date Am not eligible
Fill out all applicable fields
Renewal No. Date
If you are certified or licenses in another state, give the state and dates below.
Professional Memberships

NOTIFICATION AND RELEASE AUTHORIZATION
In connection with my application for employment with Wellsprings Post Acute Center, I understand that you will be requesting information from various companies as listed below concerning my Social Security number, motor vehicle operation history, and criminal history to the extent permitted by law from various local, state, and federal agencies, private and insurance sources, and other public records available. Further, I understand that a consumer and/or investigative report will be requested from various companies as listed below that will include information as to my character, general reputation, personal characteristics, mode of living, work habits, performance, and experience, along with reasons for termination of past employment from previous employers.
I voluntarily and knowingly authorize any present or past employer or supervisor, college or university or other institution of learning; Administrator; Law Enforcement Agency, State Agency, Local Agency, Federal Agency; Finance Bureau/Office; Credit Bureau; Collection Agency; Private Business; Military Branch or the National Personnel Records Center; Personal Reference; and/or other persons to give records of information they may have concerning my criminal history, motor vehicle history, social security number, earnings history, credit history, character and employment (including reasons for termination) or any other information requested by various companies as listed below. I voluntarily and knowingly unconditionally release any named or unnamed informant from any and all liability resulting from the furnishing of this information. This authorization shall be valid for one year from the date signed and shall automatically renew for successive one year terms at each anniversary date unless written notice not to renew is provided by me to Wellsprings Post Acute Center thirty days prior to each annual anniversary. A photographic or faxed copy of this authorization shall be as valid as the original.*

Signature
ID Information Direct - Application Notification / Release of Information
The purpose of this form is to notify you that a Consumer Report and/or Investigative Consumer Report will be conducted on you in the course of consideration for employment. I hereby authorize your company or any agent of your company to contact any and all corporations, former employers, credit agencies, educational institutions, law enforcement agencies, city, state, county, and federal courts and military services to release information about my background including, but not limited to, information about my employment, education, consumer credit history, driving record, criminal record, and general public records history to the person or company with which this form has been filed. This releases the aforesaid parties from any liability and responsibility for collecting the above information. This release shall remain in effect for the length of my employment. I understand I have the right to obtain a free copy of this consumer report if; (1) Any adverse action/decision is made based on the information in the consumer report, & (2) If the request is made in writing within 60 days of the adverse action. If an investigative consumer Report is conducted, I will be notified in writing within three days from the request of said report. I Believe to the best of my knowledge that all information I have provided is accurate true and correct and that I fully understand the terms of this release.
Name

Last, First, Middle
List any other names used in the last 7 years.
Date of Birth
Social Security Number

(This is not a secure form)
Drivers License

List State
Phone Number

(Day)
Professional License Held

List State and License Number
List your current Mailing address as well as any other cities or towns you have lived in the past 7 years.
List Street or PO Box#, City, State, Zip, and the dates
Signature

By typing your name this counts as your legal signature.
Today's Date
California residents, initial here if you wish a free copy of this report be mailed to the address you supplied above.
Employment Verification
I authorize all former employers to furnish any information concerning my employment and/or background and release them from all liability in connection with their doing so.
Re:
Social Security
Applicant Signature

By typing your name above that counts as your legal signature.
Date
Resume
Accepted file types: pdf, doc, docx, Max. file size: 64 MB.
Please attach your resume here.

Last High School Name	Address	Last Grade Completed	Major	Diploma

Junior College School Name	Address	Last Grade Completed	Major	Diploma

College or University School Name	Address	Last Grade Completed	Major	Diploma

Graduate School Name	Address	Last Grade Completed	Major	Diploma

Trade/Nursing School Name	Address	Last Grade Completed	Major	Diploma

Step 1 of 5

PERSONAL INFORMATION

GENERAL DATA

EDUCATIONAL RECORD

EMPLOYMENT RECORD

Personal References

Unemployment History

NOTICE TO APPLICANT

ONLY Professional and Technical applicants are to complete this section.

NOTIFICATION AND RELEASE AUTHORIZATION

ID Information Direct - Application Notification / Release of Information

Employment Verification

Name of Employer	Duties and Title	Started Work (Month/Year)	Left Work (Month/Year)

Address of Employer (include zip code)	Reason for Leaving

Telephone Number (area code first)	Your Supervisor	May we Contact (Y or N)	Rate of Pay

Name of Employer	Duties and Title	Started Work (Month/Year)	Left Work (Month/Year)