Wells | HC

Application Form

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability,medical condition, national origin, or marital status. The following characters cannot be used on this form (%,&,/,?,>,<,|,{,})

Personal Information

First Name

Middle Name

Last Name

DOB

Work Phone

Home Phone

Cell Phone

Cell Phone Provider

How did you hear about us?

Have you ever been convicted of a crime?

Address 1

Address 2

City

State/Prov

Zip Code

Position Applying For

SSN (NNN-NN-NNNN)

Confirm SSN

Emergency Contact

Name

Alt Phone

Address

State

Phone

Relationship

City

Zip Code

Transportation

Do you have a car?

If you don’t have a car how would you get to work?

Driver’s License #

Expiration

Availability

How many hours can you work weekly?

Would you consider live-in?

Available to Start Date

Are you available to work nights?

Employment Desired

Are you available to work weekends?

Are there any times you are not available to work?

Are you legally authorized to work in this country?

Education

High School

Name

City

State/Prov

Level Completed

Degree

Major

Certifications and Professional Licenses

License number

Expiration date

Attributes

Please indicate whether you have assisted with or performed the following tasks

Companionship

Meal Preparation

Light Housekeeping

Bathing/Showering

Dressing/Grooming

Transferring

Incontinence Care

Dementia / Alzheimers

Additional Skills

Employment History (list most recent first)

Company

Reason Left

Job Title

From

Duties

Supervisor

Phone

May we contact?

Professional References (manager, supervisor, etc.)

Name

Relationship

Years Known

Phone

Certification and Release Section

I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that the withholding, misrepresentation or falsification of information shall be grounds to refuse employment, or, if employed, shall be grounds for dismissal.

Date

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