Step 1 of 5 20% 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. GENERAL DATA Acceptance as an employee may be contingent on passing a physical examination.Type of Work Desired Full Part Time Temporary Will you work any shift? Yes No If yes, shift preferred If no, shift you will work Have you ever been employed here before? Yes No If yes, when? And where? Who referred you for employment? Do you have transportation? Have you ever been convicted of a crime? Yes No If yes, please explain: Are you related to anyone working here? If yes, who? EDUCATIONAL RECORDSchool AttendedLast High School NameAddressLast Grade CompletedMajorDiploma School AttendedJunior College School NameAddressLast Grade CompletedMajorDiploma School AttendedCollege or University School NameAddressLast Grade CompletedMajorDiploma School AttendedGraduate School NameAddressLast Grade CompletedMajorDiploma School AttendedTrade/Nursing School NameAddressLast Grade CompletedMajorDiploma Adult Education and Special Training Foreign Language: Read, Speak and WriteMachines Operated Type: Yes No W.P.M. Special Training Received 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 1Name of EmployerDuties and TitleStarted Work (Month/Year)Left Work (Month/Year) Job 1Address of Employer (include zip code)Reason for Leaving Job 1Telephone Number (area code first)Your SupervisorMay we Contact (Y or N)Rate of Pay Job 2Name of EmployerDuties and TitleStarted Work (Month/Year)Left Work (Month/Year) Job 2Address of Employer (include zip code)Reason for Leaving Job 2Telephone Number (area code first)Your SupervisorMay we Contact (Y or N)Rate of Pay Job 3Name of EmployerDuties and TitleStarted Work (Month/Year)Left Work (Month/Year) Job 3Address of Employer (include zip code)Reason for Leaving Job 3Telephone Number (area code first)Your SupervisorMay we Contact (Y or N)Rate of Pay Job 4Name of EmployerDuties and TitleStarted Work (Month/Year)Left Work (Month/Year) Job 4Address of Employer (include zip code)Reason for Leaving Job 4Telephone Number (area code first)Your SupervisorMay we Contact (Y or N)Rate of Pay Job 5Name of EmployerDuties and TitleStarted Work (Month/Year)Left Work (Month/Year) Job 5Address of Employer (include zip code)Reason for Leaving Job 5Telephone Number (area code first)Your SupervisorMay we Contact (Y or N)Rate of Pay Personal ReferencesTwo 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 HistoryPlease 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 APPLICANTThe 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 fieldsCertification No.DateAm eligible Fill out all applicable fieldsLicense No.DateAm not eligible Fill out all applicable fieldsRenewal 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.* SignatureID Information Direct - Application Notification / Release of InformationThe 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, MiddleList any other names used in the last 7 years. Date of Birth Social Security Number (This is not a secure form)Drivers License List StatePhone Number (Day)Professional License Held List State and License NumberList 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 VerificationI 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 ResumeAccepted file types: pdf, doc, docx, Max. file size: 64 MB.Please attach your resume here.