APPLICATION FOR EMPLOYMENT
BETHANY LUTHERAN HOME
BETHANY HEIGHTS
An Equal Opportunity Employer
Date_______________________ Position Applied for 1.____________________________ 2._____________________
Personal Information
_________________________________________________________________________________________________________
Last Name
First Name
Middle Name
_______________________________________________________________________________________
Street Address
City
__(______)_______________________________
Home Phone
_____________________________________________
Social Security Number
State
Zip
_________________________________________________________
Phone Number for messages
Yes ______________________ No ___________________
Are you 1 6 years of age or over?
Have you worked under another name? ___No ___ Yes. If you answered yes, list name__________________________________
Have you been employed by us before? ___No ___ Yes. (If yes, state date and jobs):___________________________________
Do you have relatives employed by us? ___No ___ Yes, the following relative(s) ______________________________________
Are you a citizen of the United States or specifically eligible to work in the U.S. ___Yes ___No
Have you ever been convicted of a violation of the law other than a minor traffic violation? ______No
___Yes Dates(s) convicted_______________ If yes, explain and give details________________________________________
________________________________________________________________________________________________________
A conviction record will not necessarily disqualify you from employment. The circumstances of a conviction will be considered in
relation to the nature and duties of the job for which you apply.
How did you hear about the organization?
 Bethany’s website
 social media
 advertising
 employment website (which one) __________________
 word of mouth
 other _____________
WORK AVAILABILITY
From Am\Pm
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
To Am\Pm
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
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Are you a citizen of the United States, or specifically authorized to be employed in the United States?
Yes
No
Note: The law requires that you provide evidence and a sworn statement of your citizenship or work authorization if you
are hired. Any offer of employment which you receive is contingent upon your providing the documentation and statement
which we will request from you.
PRIOR EMPLOYMENT
List your last three jobs, beginning with the most recent (you may omit dates for jobs held more than five
years ago). May we contact your employer?
Yes
No
1. Employer name: ____________________________Supervisor Name__________________________
Employer Address: ____________________________________________ Phone: __________________
Job Title________________________________Duties_________________________________________
Dates employed ___________________ to _____________________ Salary $ _____________________
Reason leaving_________________________________________________________________________
2. Employer name: ____________________________Supervisor Name __________________________
Employer Address: _____________________________________________ Phone: _________________
Job Title _______________________________ Duties _______________________________________
Dates employed ___________________ to _____________________ Salary $ ____________________
Reason for leaving _____________________________________________________________________
3. Employer name: ___________________________ Supervisor Name _________________________
Employer Address: ____________________________________________ Phone: _________________
Job Title ________________________________ Duties______________________________________
Dates employed ____________________ to ____________________ Salary $ ___________________
Reason for leaving ____________________________________________________________________
Bethany Lutheran Home is an equal opportunity employer. We will not discriminate and will take affirmative action measures to ensure against
discrimination in employment, recruitment, advertisements for employment, compensation, termination, promotions, and other conditions of
employment. If you believe you have been discriminated against contact the Compliance Officer or the Chief Operating Officer.
EDUCATION AND TRAINING
Name and location of high school __________________________________________ Graduated?
Yes
No
Please list technical or trade school, college, and post-graduate education, if any:
School/College
Level Completed
Degree
Major Subjects
_________________________
_____________________
__________________
_______________________________
_________________________
_____________________
__________________
_______________________________
_________________________
_____________________
__________________
_______________________________
_________________________
_____________________
__________________
_______________________________
OTHER SKILLS
Describe any special skills or qualifications which may help you in the position applied for:
_________________________________________________________________________________________________________
List all licenses or certificates held, including state, license or certificate type, date issued, and license or certificate number:
_________________________________________________________________________________________________________
List any relevant professional or business organizations to which you belong (Optional):
_________________________________________________________________________________________________________
VAN DRIVER ONLY
How long have you been a licensed driver? ____________________________________________________________________
Current driver’s license:
State __________________
Number ________________________________________
Expires on _____________________
VETERAN STATUS
If you are a veteran of the armed forces of the United States, please provide the following information:
Military Branch:_________________________________ dates of Service:__________________________________________
Discharge Date: _________________________________ Honorable Discharge? ___Yes
___No
Note: a less than honorable discharge will not automatically disqualify you from employment.
REFERENCES
Please list two personal references, other than prior employers or relatives, whom we can contact.
1.
Name __________________________________________________
How long known? ___________________________
2.
Occupation _______________________________________
Name __________________________________________________
How long known? ___________________________
Phone (____)____________________
Phone (____)____________________
Occupation _______________________________________
Bethany Lutheran Home / Bethany Heights
_____________________________________________
Name of Applicant
By signing below, I certify that the answers and information set out above are true, accurate and complete to the best of
my knowledge. I acknowledge that if any answer or information is not true, accurate or complete, I may not be hired,
or if hired, I may be discharged. I authorize Bethany Lutheran Home / Bethany Heights to investigate all statements
contained in this application for employment and to investigate my character and qualifications. I authorize my prior
employers, references, and others with information regarding my work or educational history or my character, to
provide Bethany Lutheran Home / Bethany Heights with all requested information and references, and to cooperate
fully with the investigation of my character and qualifications.
I understand that this application is not a contract of employment. I also acknowledge that no oral
representations have been made, and that no one within Bethany Lutheran Home / Bethany Heights has
the authority to make oral contracts of employment. If hired, my employment relationship with Bethany
Lutheran Home / Bethany Heights is terminable at-will, with or without cause, by either myself or
Bethany Lutheran Home / Bethany Heights.
I understand that employment will be conditional upon successful completion of a State Department of Public Safety
background check and the Office of the Inspector General (OIG) / System for Award Management (SAM) Excluded
Parties List System check.
I also understand that any offer of employment may be conditional upon by passing a pre-employment physical
examination and/or a drug/alcohol test administered by a health care professional selected by Bethany Lutheran Home
/ Bethany Heights, to which I hereby consent.
I understand and agree to all of the conditions and statements set forth above, and throughout this application.
__________________________________________
Applicant’s Signature
___________________________________________
Date and Time
CONFIDENTIAL REFERENCE REQUEST
CONFIDENTIAL REFERENCE REQUEST
Concerning (name) ______________________________________________________________________
Address _______________________________________________________________________________
______________________________________________________________________________________
I hereby authorize the facility/institution named below to release all information requested on this confidential reference request.
X_________________________________________ X ___________________________
Applicant's Signature
Date
BELOW - FOR OFFICE USE ONLY
______________________________________________________________________________________________________
Dear Sir or Madam:
The above-named applicant has indicated that he/she was previously employed by you. Your evaluation of him/her will be
sincerely appreciated, and will be held in complete confidence. Both the applicant and I will benefit from an early reply, since
his/her employment is pending. Thank you.
Name ___________________________________________________
Title ____________________________________________________
Facility__________________________________________________
Address___________ ______________________________________
__________________________________________________
Dates of employment: From_________________________to___________________________________
Position or title:________________________________________________________________________
Duties and/or responsibilities:_____________________________________________________________
Reason for leaving:______________________________________________________________________
Would you re-hire? _____Yes _____No If not, why not?_____________________________________
Quality of Work:
Good
Adequate
Poor
Quantity of Work:
Good
Adequate
Poor
Attendance:
Good
Adequate
Poor
Cooperation:
Good
Adequate
Poor
Initiative:
Good
Adequate
Poor
Other comments (your remarks are the most important part of this questionnaire):
______________________________________________________________________________________
Signed____________________________________________________
Title _____________________________________________________
Date _____________________________________________________
10.26.2016 bh