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Application for Employment

Personal Information



Address







*Are you 18 years of age?
*Are you legally eligible to work in this country?



*Status Desired?


*Have you ever filled out an application with us before?

*Have you ever been employed with us before?

*Are you able to perform the essential job related functions of the position for which you are applying?
*May we contact your present employer?
*May we contact your previous employers?
*How did you hear about us?
*Have you ever been convicted or pleaded guilty to a Felony or Misdemeanor crime?

*Have you served in the United Sates Armed Forces?



EducationName/Address of SchoolLast Year Completed (1,2,3,4)Did you Graduate?Degree/Diploma
High School
College
Nursing
Other


Employment RecordPlease start with your present or most recent employer. Be prepared to account for all periods of unemployment at interview.











*May we check this reference?












*May we check this reference?












*May we check this reference?

Professional References (Please do not use names of relatives)
 NameOccupationPhone NumberRelationship
1.
2.
3.


I hereby certify that the information contained in this application is true and correct, and I authorize personnel representatives of Bethany Village to contact my schools, former employers, or other references unless otherwise stated. This is to be done for the purpose of collecting information and an account of their experience with me.

I understand that if I am employed, and misrepresentation of the fact as stated or implied on this application is sufficient cause for dismissal. I also understand that I may be required to successfully complete a medical examination before employment. This agreement does not bind either party for any specific period regarding employment.



Please enter the following



AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER

Federal and State Laws prohibit discrimination because of age, sex, race, creed, color, national origin, marital status, sexual orientation, or disability. Bethany Village is an equal employment opportunity employer and complies with these laws.