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 7 14% Position(s) Applied For Name* First Middle Last 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 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 InformationPlease list name and address of school and number of years attended.High School InformationPlease list name and address of school, number of years attended, and completed degree.Undergraduate CollegePlease list name and address of school, number of years attended, course of study, and completed degree.Graduate ProfessionalPlease 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 ExperienceStart 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 1Employer name, address, and phone numberWork performedJob Title Supervisor Dates Employed Enter starting date & ending dateHourly Rate / Salary Enter starting & final rates.Position 2Employer name, address, and phone numberJob Title Work performedSupervisor Dates Employed Enter starting date & ending dateHourly Rate / Salary Enter starting & final rates.Position 3Employer name, address, and phone numberJob Title Work performedSupervisor Dates Employed Enter starting date & ending dateHourly Rate / Salary Enter starting & final rates.Position 4Employer name, address, and phone numberJob Title Work performedSupervisor Dates Employed Enter starting date & ending dateHourly 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 QualificationsSummarize 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 skillsTyping / 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 addressReference #2 -- Please give the name, address, phone number and email addressReference #3 -- Please give the name, address, phone number and email addressBethesda 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. Applicant'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.
