Wellspring Homecare Application for Employment

Thank you for your interest! Wellspring Homecare is the industry leader in providing homecare services to seniors who want to remain independent in our Rest Homes. One of our goals is to enhance and enrich the quality of life with each client in the way we interact and by the services we provide. We realize that the people we employ are entrusted to care for our clients and therefore we hire individuals who are passionate about serving. At Wellspring Homecare, we pride ourselves in caring for others and ensuring their comfort, safety and needs.

At Wellspring Homecare, we strive to achieve the highest standard in homecare. Our values are not just words, but a way of doing business!

Education
Name of High School: Years Attended: Did you graduate?

YesNo
Name of College: Years Attended: Did you graduate?

YesNo Degree
Name of Graduate School: Years Attended: Did you graduate?

YesNo Degree
Name of Professional Organization Years Attended
Diploma/Licenses Obtained
Scholastic Honors
Do you have any additional skillscertification you wish to let us know about

EMPLOYMENT HISTORY

Starting with your most recent employer, list all previous employers, including self-employment, part-time or verifiable volunteer work.
Company
Dates of Employment

MonthDayYear
Date
From
To
Address
Telephone
Starting Salary
Ending Salary
Supervisors Name
Contact Phone Number
Email Contact
example@example.com
Position and Duties
Reason for Leaving
May we contact your previous employer for a reference?

YesNo
Company
Dates of Employment

MonthDayYear
Date
From
To
Address
Telephone
Starting Salary
Ending Salary
Supervisors Name
Contact Phone Number
Email Contact
example@example.com
Position and Duties
Reason for Leaving
May we contact your previous employer for a reference?

YesNo
Company
Dates of Employment

MonthDayYear
Date
From
To
Address
Telephone
Starting Salary
Ending Salary
Supervisors Name
Contact Phone Number
Email Contact
example@example.com
Position and Duties
Reason for Leaving
May we contact your previous employer for a reference?

YesNo
Please state any other work experience including civic trade or business organizations you believe might be of value to Wellspring Homecare You may exclude membership which would reveal your race color age religion national origin mental or physical disability sexual orientation or ancestry

REFERENCES

Please list three non-related professional references:
Name
Company
Telephone
Years Known
Name
Company
Telephone
Years Known
Name
Company
Telephone
Years Known
By processing this employment application Wellspring Homecare may request that a bonding investigative consumer report be prepared, which may include credit bureau reports, employment references, educational achievements, and information as to your character, general reputation and criminal record, your signature below indicates your assent to this. I hereby authorize Wellspring Homecare to report any information to any prospective employer, governmental agency or any other person or entity having a legitimate business need concerning any transactions or experiences between myself and Wellspring Homecare arising out of my employment. I understand that, upon employment, I must provide proof of employment authorization and proof of identity. Failure to do SO in accordance with federal specifications will result in immediate employment termination. I understand that if I am hired, the length of my employment is not guaranteed. Recognizing that I will be free to voluntarily terminate my employment at any time, with or without cause, I acknowledge that Wellspring Homecare will be free to terminate my employment at any time, with or without cause. The facts set forth in my application for employment and any attached resumes are true and complete. I understand that, if employed, any false statement or deliberate omission may result in my dismissal.

I hereby acknowledge that I have read the above statements and understand them. I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that falseor misleading information in my application or interview may result in my release.
Signature of Applicant

Clear
Date

MonthDayYear
Date
Should be Empty:

Application for Employment

Education

EMPLOYMENT HISTORY

REFERENCES