Employment Application - Woodbury Wellness & Stonebridge at Woodbury
Woodbury Wellness Center, Inc. is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, or veteran status.
Your Contact Information Date of Application *
Date Available to Begin Employment *
First Name * Last Name * Phone Number * Email Address *
Permanent Address * City, State * Zip * Present Address Alternate Phone Number Social Security # (To Be Given Voluntarily) Which position(s) are you applying for? * Will you accept employment of: * Are you 18 years of age or older? * Are you eligible for employment in a full-time job in the USA? * Have you been employed with Woodbury Wellness Center, Inc.? * If so, when? Start date:
How did you learn of this employment opportunity? * Type of Work Desired First Choice First Choice Shift & Salary Second Choice Second Choice Shift & Salary Third Choice Third Choice Shift & Salary Education Select Highest Grade Completed * High School High School (Name of School) Completed Location (City, State) Courses Taken Type of Degree or Certificate Received College College (Name of School) Completed Location (City, State) Courses Taken Type of Degree or Certificate Received Vocational Vocational (Name of School) Completed Location (City, State) Courses Taken Type of Degree or Certificate Received Professional Education Professional Education (Name of School) Completed Location (City, State) Courses Taken Type of Degree or Certificate Received Extracurricular Activities Extracurricular Activities While in School Member of Professional Organizations Honors Received, Volunteer, or Community Service or Other Qualifications you have which you feel are related to the position for which you are applying: Professional Licenses and/or Certificates Type Organization/State Issued Date Issued
Number Verification Type Organization/State Issued Date Issued
Number Verification Type Organization/State Issued Date Issued
Number Verification Employment Record (list last or present position first) Position One Name * Address * City, State, Zip * Supervisor * Phone Number * Reason for Leaving * May We Contact This Employer * If no, please explain why: Position and Duties * Start Date
Starting Salary Rate Ending Salary Rate Position Two Name * Address * City, State, Zip * Supervisor * Phone Number * Reason for Leaving * May We Contact This Employer * If no, please explain why: Position and Duties * Start Date
Starting Salary Rate Ending Salary Rate Position Three Name * Address * City, State, Zip * Supervisor * Phone Number * Reason for Leaving * May We Contact This Employer * If no, please explain why: Position and Duties * Start Date
Starting Salary Rate Ending Salary Rate Position Four Name Address City, State, Zip Supervisor Phone Number Reason for Leaving May We Contact This Employer If no, please explain why: Position and Duties Start Date
Starting Salary Rate Ending Salary Rate Position Five Name Address City, State, Zip Supervisor Phone Number Reason for Leaving May We Contact This Employer If no, please explain why: Position and Duties Start Date
Starting Salary Rate Ending Salary Rate If your former employment references or education are under a name other than indicated on top of application, please indicate below. In the past 10 years, have you been convicted of a crime other than a minor traffic offense? * If yes, please explain below. (A conviction will not necessarily automatically disqualify you for employment. Rather, such factors as age, date of conviction, seriousness, nature of the crime, and rehabilitation will be considered.) Use this space to give us further information which will be assist us in placing you. Personal References (Someone who you have known longer than 1 year.) Name * Phone Number * Relationship * Name * Phone Number * Relationship * Availability Record Are you available to work: Weekends * Holidays * Rotating Shifts * Do you limit your annual earnings due to Social Security or other reasons? * If yes, please state what is the maximum amount you wish to earn:
If your availability changes, it is your responsibility to fill in an "availability card" indicating the changes. Such changes will be effective, then, for any future employment.
Please indicate what DAYS and HOURS you are available to work. (Be specific.) Sunday (AM-PM) Monday (AM-PM) Tuesday (AM-PM) Wednesday (AM-PM) Thursday (AM-PM) Friday (AM-PM) Saturday (AM-PM)
I understand emergency conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling change directed by my department head or administrator of this institution.
Signature (Please type) *
I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize Woodbury Wellness Center, Inc. to verify their accuracy and to obtain reference information on my work performance. I hereby release Woodbury Wellness Center, Inc. from any/all liability of whatever kind and nature which, at any time,
could result from obtaining and having an employment decision based on such information. I understand that,
if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal.
I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules, and regulations of employment of the employer. However, I further understand that neither the policies, rules, and regulations of employment or anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. I understand that any employment offered is for an indefinite duration and at will and that either I or the employer may terminate my employment at any time with or without notice or cause.
Signature (Please type) * Date *
Consent and Release Form - Drug Testing
As an applicant desiring employment with Woodbury Wellness Center, Inc., you are required to read and sign this form. Failure to sign will result in your being barred from further consideration for employment with this company.
Woodbury Wellness Center, Inc. is firmly committed to maintaining a drug-free work place and has a responsibility to provide a safe work environment for employees and to prevent injuries to the general public. Therefore, reporting to work under the influence of or working while impaired by alcohol or unprescribed or illegal narcotics or drugs, or using, possessing, selling, buying or transferring unprescribed or illegal narcotics or drugs off company premises is prohibited.
Each applicant for a position with Woodbury Wellness Center, Inc. will be subject to the company substance abuse program. All offers of employment to applicants will be contingent upon the applicant passing a drug test in accordance with Woodbury Wellness Center, Inc. drug testing procedures. An applicant who refuses to submit to pre-employment testing when requested, or refuses to sign the company Consent and Release of Liability for Drug Testing form, will not be employed by Woodbury Wellness Center, Inc. If the applicants test is positive for any prohibited substance not prescribed by a physician, they will not be employed by Woodbury Wellness Center, Inc.
I have read and understand these requirements. I accept the conditions for consideration of employment and, if employed, as a condition of continued employment. I consent to the requirements the drug screen test. The testing agency is authorized by me to provide the results of such tests to Woodbury Wellness, Inc.. I understand that the results of such tests will remain the property of Woodbury Wellness Center, Inc., and will not be used for any unauthorized purpose. I further agree to hold the testing company and/or Woodbury Wellness Center, Inc., its agents, directors, officers and employees harmless from any and all liability in connection with such tests or the direct deposit requirement. I understand that all employment with the company is at-will and that nothing in this consent constitutes a guarantee of or creates a contract of employment.
Signature (Please type) * Date *
Voluntary Applicant Self-Indentification Survey
Woodbury Wellness Center, Inc. is a federal government contractor. As a matter of Woodbury Wellness Center policy as well as applicable law, we are required to keep records and perform certain analyses of our applicant pool by race, ethnicity, and gender. Such analyses are only possible if we know the EEO profile of our applicants, so we request that you complete this survey and return it to us promptly.
Although the information that applicants provide does not at all affect their prospects for employment and is, in fact, treated very confidentially, it is nevertheless very important to us. For any statistical analyses to be meaningful, we must have information on as many applicants as possible and it is just as important to collect this information from men and from non-minorities as it is to obtain it from women and minority group member.
We appreciate that some applicants will find this request intrusive and we regret this. However, please be advised that we are required by the government to keep such records and perform such analyses. You may decline to disclose bu your cooperation will allow us to be accurate.
In addition, information on county and stat of resident as well as on how you about the vacancy you applied for will assist us in our recruitment efforts. The categories listed below are those use by the US Department of Labor. Although some agencies have expanded these categories to permit multi-racial reporting, the Department of Labor has not yet done so and, we regret, these are the only options we can offer at this time.
Gender Race or Ethnicity Name Zip Code Country & State of Residency How did you learn of this vacancy? If by advertisement, please give name & date of publication. Position applied for (must be specific) Vantage Point - Disclosure and Release Form
As part of the application process for employment at Woodbury Wellness Inc., I understand that they and/or its agents may conduct an investigation of my personal information. The investigation might include, but is not limited to names and date of previous/current employment, work experience, workers' compensation claims, criminal history records (from state, federal and other agencies), motor vehicle records, names and dates of education, credit history, and bankruptcy records. I understand that these records may be used for the eligibility of my employment. I authorize without reservation the full release of these records and for Vantage Point Services and/or its agents contacted by Vantage Point Services to obtain this information. In addition, I release and discharge Vantage Point Services, and all of its agents and associates, any expenses, losses, damages, liabilities, or any other charges or complaints for the investigation process. I also authorize the full release of the information described above, without any reservation, through any duration of my employment at Woodbury Wellness Inc.. this may include on-going, post-hire review of public records for any possible criminal offense charges. I also certify that all information provided is correct on the application and my resume to the best of my knowledge. Any false statements provided will be considered just cause for termination of employment. Upon request, Vantage Point Services will supply a copy of my report and my rights under the Fair Credit Reporting Act. Requests may be directed to: Vantage Point Services PO Box 1589 Fuquay Varina, NC 27526 or by contacting them at 1-800-792-4339.
Applicant's Name (First, Middle, Last) * Signature * Date *
Date of Birth *
Social Security Number Driver's License Number State Current Address (Street, City, State, Zip) Length of Residency
If you have lived outside of NC in the last 5 years please include the address below (street, city, state, zip).