Employment Application 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 8 12% Application date: Position(s) applied for: Legal Name* First Middle Last Preferred Name Birth Gender Gender Identity Present Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email Are you over the age of 16? Yes No Best time to contact you Times you are available to work Full Time (30-40) Part Time A (20-30) Part Time B (less than 20) PRN (when called) Shift Preference Days Evenings Nights Weekends Would you work overtime if asked? Yes No Would you work other shifts or times if asked or available? Yes No What is your desired salary range? Date available to begin work? Have you worked 40 hours or more in the last 60 days? Yes No Are you currently employed? Yes No May we contact your current employer? 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 Are you under 18 years of age? 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 applied at Bethesda before? Yes No If yes, give date: Department: Have you ever worked for us before? Yes No If yes, give date: Department: Do you have any friends or relatives who work here? Yes No If yes, give name and relationship: How did you learn about us? Friend/Relative Advertisement Employment Agency Social Media 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 ever 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 If yes, explain: Have you ever been convicted of a felony? 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.If yes, explain: 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 and if so, what state? EducationGraduatePlease list name and location of school, course of study, number of years attended, and completed degree.CollegePlease list name and location of school, course of study, number of years attended, and completed degree.High SchoolPlease list name and location of school, course of study, number of years attended, and completed degree. Employment ExperienceStart with your present or last job.Position 1Employer name, address, and phone numberSupervisor Dates Employed Enter starting date & ending dateHourly Rate / Salary Enter starting & final rates.Job title and duties:Reason for leaving:May we call this employer for a reference? Yes No If no, why not? Position 2Employer name, address, and phone numberSupervisor Dates Employed Enter starting date & ending dateHourly Rate / Salary Enter starting & final rates.Job title and duties:Reason for leaving:May we call this employer for a reference? Yes No If no, why not? Position 3Employer name, address, and phone numberSupervisor Hourly Rate / Salary Enter starting & final rates.Dates Employed Enter starting date & ending dateJob title and duties:Reason for leaving:May we call this employer for a reference? Yes No If no, why not? Position 4Employer name, address, and phone numberSupervisor Dates Employed Enter starting date & ending dateHourly Rate / Salary Enter starting & final rates.Job title and duties:Reason for leaving:May we call this employer for a reference? Yes No If no, why not? List professional, trade, business or civic activities and offices held: List all other names you have used other than the names listed on this application, such as maiden name, name prior to legal name change, etc.: References (other than family)Reference #1: Please give the name, relationship, and phone numberReference #2: Please give the name, relationship, and phone numberReference #3: Please give the name, relationship, and phone numberApplicant's StatementSignature* 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.Bethesda Home Mission, Vision, and Core ValuesSignature* 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.
