Bethesda Home & Retirement Center

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Employment Application

We consider applications for all positions without regard to race, color, religion, creed, sex, national origin, disability, sexual orientation, citizenship status or any other legally protected status.

Step 1 of 7

14%

Position(s) Applied For
Name*
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email

Employment Type Desired
- Full-time
- Part-time
- Temporary
When are you available to work?
- 1st Shift / Mornings
- 2nd Shift / Afternoons
- 3rd Shift / Evenings
What is your desired salary range?
Are you currently employed?
- Yes
- No
Are you currently on lay-off status and subject to recall
- Yes
- No
Can you travel if a job requires it?
- Yes
- No
Best time to contact you at home is:
May we contact your present employer?
- Yes
- No

If you're under 18 years of age, can you provide required proof of your eligibility to work?
- Yes
- No
Have you ever filed an application with us before?
- Yes
- No
If yes, give date:
Have you been employed with us before?
- Yes
- No
If yes, give date:
Do any of your friends or relatives, other than your spouse, work here?
- Yes
- No

How did you hear about us?
- Advertisement
- Relative / Friend
- Inquiry
- Employment Agency
- Other
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
- Yes
- No
Proof of citizenship or immigration status will be required upon employment.
Have you even been convicted of any crimes in the past 10 years, including misdemeanors and summary offenses, which have NOT been annulled, expunged or sealed by the court?
- Yes
- No
Have you ever been convicted of a felony within the last five years?
- Yes
- No
A criminal record does not constitute an automatic bar to employment and will be considered only as it relates to the job in question.
Have you ever been excluded from receiving federal contracts, certain subcontracts or certain federal financial and non-financial assistances and benefits?
- Yes
- No
Have you ever been excluded from Medicare, Medicaid or any other federal health care program?
- Yes
- No
Have you ever been licensed to work in another state?
- Yes
- No
If so, which state?
Elementary School Information
Please list name and address of school and number of years attended.
High School Information
Please list name and address of school, number of years attended, and completed degree.
Undergraduate College
Please list name and address of school, number of years attended, course of study, and completed degree.
Graduate Professional
Please list name and address of school, number of years attended, course of study, and completed degree.
Other (Specify)
Describe any specialized training, apprenticeship, skills and extra-curricular activities.
Describe any job-related training received in the United States military.

Employment Experience
Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status.
Position 1
Employer name, address, and phone number
Work performed
Job Title
Supervisor
Dates Employed
Enter starting date & ending date
Hourly Rate / Salary
Enter starting & final rates.
Position 2
Employer name, address, and phone number
Job Title
Work performed
Supervisor
Dates Employed
Enter starting date & ending date
Hourly Rate / Salary
Enter starting & final rates.
Position 3
Employer name, address, and phone number
Job Title
Work performed
Supervisor
Dates Employed
Enter starting date & ending date
Hourly Rate / Salary
Enter starting & final rates.
Position 4
Employer name, address, and phone number
Job Title
Work performed
Supervisor
Dates Employed
Enter starting date & ending date
Hourly Rate / Salary
Enter starting & final rates.

List professional, trade, business or civic activities and offices held.
You may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status:
Other Qualifications
Summarize special job-related skills and qualifications acquired from employment or other experience.
Special Skills (check skills/equipment operated)
- Terminal
- PC/MAC
- Typewriter
- Spreadsheet
- Word Processing
- Shorthand
List any other skills
Typing / Shorthand WPM, Production / Mobile equipment, Other.
Can you perform the essential functions of the job, for which you are applying, either with or without a reasonable accommodation?
- Yes
- No
DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Reference #1 -- Please give the name, address, phone number and email address
Reference #2 -- Please give the name, address, phone number and email address
Reference #3 -- Please give the name, address, phone number and email address
Bethesda Home Mission, Vision, and Core Values
Signature*
First Last
Our Mission: Bethesda seeks to be a community formed by the spirit of Jesus Christ to fulfill the lives of adults with special needs in a place that is home

Our Vision: Bethesda will be a regenerative community for all residents, staff, board and families. Bethesda will achieve its mission by honoring these

Core Values:
1. Treasure every person
2. Practice daily welcome and hospitality
3. Listen with the heart, hold confidences, forgive
4. Name losses and celebrate joys
5. Foster choice, creativity and playfulness
6. Develop servant leaders who seek supervision and foster excellence
7. State goals, accept risks, be accountable
8. Change unjust practices and negotiate conflicts
9. Enlarge, develop and complete life, receiving and giving blessings.

I am in agreement with the mission, vision and core values of Bethesda and, if employed, I agree to conduct myself in accordance with them with full knowledge that violation may result in disciplinary action up to and including termination. I certify that the information I provided in this application for employment is true. False, incomplete or misrepresented information will be sufficient cause for my application to be rejected, or, if discovered after I am employed, cause for immediate termination of my employment.
Applicant's Statement
Signature*
First Last
Please read and understand this statement before signing your application: I understand this application shall be considered active for 90 days. I authorize the employer to obtain information about me from previous employers, educational institutions, government and law enforcement agencies and other parties, to verify the accuracy of information in this application, a related employment resume or personal interview. I waive all rights and claims I may otherwise have against the employer or its representatives, for seeking, and using information to evaluate my employment request and all other people who provide information for this purpose. This application is not an employment agreement. I understand that nothing contained in the employment application, granting of an interview or offer of employment is intended to create an employment contract between Bethesda and me. If I accept an offer of employment, I understand the employer may terminate my employment at any time, with or without cause and without prior notice, by Bethesda or myself. I understand that no one, other than the CEO has authority to enter into any employment agreement with terms contrary to the foregoing, and then only in writing signed by such officer. I accept all terms and conditions in the above statement.

2016 & 2018 Person-Centered Care Home Award

408 – 412 East Main / PO Box 37 / Goessel, KS 67053 / (620) 367–2291

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Employment Application

Step 1 of 7

Employment Experience

Position 1

Position 2

Position 3

Position 4

Bethesda Home Mission, Vision, and Core Values

Applicant's Statement