Application for Employment - Bethany Village

PERSONAL INFORMATION

First Name

Middle Name

Last Name

Street

City

State

Zip Code

Phone

Are you 18 years of age or older?

Yes

Are you legally eligible to work in this country?

Yes

Please list any other names (i.e. maiden name) by which you have been known to references, schools, or previous employers necessary to enable a check on your past references.

Position Desired

Date Available

Status Desired

Full-Time

Part-Time

Half-Time

Per Diem

Desired Salary

Will you work weekends and holidays if required?

Yes

Have you ever filled out an application with us before?

Yes

If yes, give date.

Have you been employed with us before?

Yes

If yes, give date.

Are you able to perform the essential job related functions of the position for which you are applying?

Yes

May we contact your present employer?

Yes

May we contact your previous employers?

Yes

How did you hear about us?

Friend / Relative

Newspaper

Internet

Other

Have you ever been convicted or pleaded guilty to a felony or misdemeanor crime?

Yes

If yes, please explain. (existence of a criminal record does not necessarily deny your employment)

MILITARY SERVICE

Have you served in the United States Armed Forces?

Yes

If yes, which branch of service?

Dates of Service

Areas of Specialized Training

EDUCATION

High School Name & Address

Last Year Completed

First (Freshman)

Second (Sophomore)

Third (Junior)

Fourth (Senior)

Did you graduate?

Yes

Did you receive a diploma?

Yes

College Name & Address

Last Year Completed

First (Freshman)

Second (Sophomore)

Third (Junior)

Fourth (Senior)

Did you graduate?

Yes

Did you receive a degree?

Nursing School Name & Address

Last Year Completed

First (Freshman)

Second (Sophomore)

Third (Junior)

Fourth (Senior)

Yes

Did you receive a degree?

Other School Name & Address

Last Year Completed

First (Freshman)

Second (Sophomore)

Third (Junior)

Fourth (Senior)

Yes

Did you receive a degree?

EMPLOYMENT RECORD

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

Name of Employer

Address

Type of Business

Position Held

Employed From Date

Employed To Date

Supervisor's Name & Title

Phone

Reason for Leaving

May we check this reference?

Yes

Name of Employer

Address

Type of Business

Position Held

Employed From Date

Employed To Date

Supervisor's Name & Title

Phone

Reason for Leaving

May we check this reference?

Yes

Name of Employer

Address

Type of Business

Position Held

Employed From Date

Employed To Date

Supervisor's Name & Title

Phone

Reason for Leaving

May we check this reference?

Yes

PROFESSIONAL REFERENCES

Please do not use names of relatives.

Name of Reference

Occupation

Phone

Relationship

Name of Reference

Occupation

Phone

Relationship

Name of Reference

Occupation

Phone

Relationship

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, any misrepresentation of the facts 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.

Signature of Applicant

Date