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 ForName* First Middle Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe 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?YesNoAre you currently on lay-off status and subject to recallYesNoCan you travel if a job requires it?YesNoBest time to contact you at home is:May we contact your present employer?YesNo If you're under 18 years of age, can you provide required proof of your eligibility to work?YesNoHave you ever filed an application with us before?YesNoIf yes, give date:Have you been employed with us before?YesNoIf yes, give date:Do any of your friends or relatives, other than your spouse, work here?YesNo How did you hear about us?AdvertisementRelative / FriendInquiryEmployment AgencyOtherAre you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?YesNoProof 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?YesNoHave you ever been convicted of a felony within the last five years?YesNoA 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?YesNoHave you ever been excluded from Medicare, Medicaid or any other federal health care program?YesNoHave you ever been licensed to work in another state?YesNoIf 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 TitleSupervisorDates EmployedEnter starting date & ending dateHourly Rate / SalaryEnter starting & final rates.Position 2Employer name, address, and phone numberJob TitleWork performedSupervisorDates EmployedEnter starting date & ending dateHourly Rate / SalaryEnter starting & final rates.Position 3Employer name, address, and phone numberJob TitleWork performedSupervisorDates EmployedEnter starting date & ending dateHourly Rate / SalaryEnter starting & final rates.Position 4Employer name, address, and phone numberJob TitleWork performedSupervisorDates EmployedEnter starting date & ending dateHourly Rate / SalaryEnter 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?YesNoDO 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.