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Employment Application
Name:
Current Address
Permanent Address
Email Address:
Home Telephone
Work Telephone
Cell Telephone
Are you 18 years of age or older? Yes
No
Have you applied at Samaritan Bethany, Inc. before? Yes
No
Have you been known by another name? Yes
No
If yes, what:
Have you ever worked for Samaritan Bethany, Inc. before? Yes
No
If yes, when?
Why did you leave?
Have you ever been convicted of a misdemeanor or felony, or been convicted in a military court martial? *A conviction is not an automatic bar to employment. The type, seriousness, frequency of violations, recency, relevancy, work history, education and other circumstances will be considered. Yes*
No
If Yes, please provide date of conviction, state and county, and describe circumstances.
What position are you applying for?
How many hours do you want to work? Full Time (54 or more hours per pay period)
Part Time (less than 54 hours per pay period)
On-Call (irregular hours)
When would you like to work? Days
Evenings
Nights
Weekends
What date could you start?
Would you like to work at a particular Samaritan Bethany, Inc. entity? (please check your preference) Samaritan Bethany Home on Eighth
Samaritan Bethany Arbor Terrace
Samaritan Bethany Heights
Samaritan Bethany Terrace
Samaritan Bethany Corporate
Why would you like to work for Samaritan Bethany Inc.?
What do you know about Samaritan Bethany Inc.?
Please give an accurate, full-time and part-time employment record. Start with your present or more recent employer. Please give complete employer name and address. Employer # 1 Name
Employer # 1 Complete Address
Employer # 1 Supervisor's Name and Title
Employer # 1 List your title and describe the work you did (Include skills that you could apply at Samaritan Bethany Inc.)
May we contact this employer? Yes
No
If no, why not?
Employer # 1 Telephone
Employer # 1 Hourly Rate
Employer # 1 Dates of Employment
Employer # 1 Explain your reason(s) for leaving:
Employer # 2 Name
Employer # 2 Complete Address
Employer # 2 Supervisor's Name and Title
Employer # 2 List your title and describe the work you did (Include Skills that you could apply at Samaritan Bethany, Inc.)
May we contact this employer? Yes
No
If no, why not?
Employer # 2 Telephone
Employer # 2 Hourly Rate
Employer # 2 Dates of Employment
Employer # 2 Explain your reason(s) for leaving:
Employer # 3 Name
Employer # 3 Complete Address
Employer # 3 Supervisor's Name and Title
Employer # 3 List your title and describe the work you did (Include skills that you could apply at Samaritan Bethany, Inc.)
May we contact this employer? Yes
No
If no, why not?
Employer # 3 Telephone
Employer # 3 Hourly Rate
Employer # 3 Dates of Employment
Employer # 3 Explain your reason for leaving:
Employer # 4 Name
Employer # 4 Complete Address
Employer # 4 Supervisor's Name and Title
Employer # 4 List your title and describe the work you did (Include skills that you could apply at Samaritan Bethany Inc)
May we contact this employer? Yes
No
If no, why not?
Employer # 4 Telephone
Employer # 4 Hourly Rate
Employer # 4 Dates of Employment
Employer # 4 Explain your reason for leaving:
Have you ever been discharged by an employer? Yes
No
If yes, please explain all terminations:
List all periods of unemployment:
How did you spend this time?
If hired by Samaritan Bethany, Inc., can you furnish proof that you are eligible to work in the United States? Yes
No
If no, please explain
High School- Name and Address
High School- Years Completed 1
2
3
4
High School- Did you graduate? Yes
No
High School- Course of Study
College/Vocational School-Name and Address
College- Years Completed 1
2
3
4
College- Did you graduate? Yes
No
College- Course of study
College- Degree earned
Graduate Studies- Name and Address of School
Graduate Studies- Years Completed 1
2
3
4
Graduate Studies- Did you graduate? Yes
No
Graduate Studies- Course of Study
Graduate Studies- Degree Earned
Other Schooling- Name and Address
Other School- Years Completed 1
2
3
4
Other School- Did you graduate? Yes
No
Other School- Course of Study
Other School- Degree Earned
Office Applicants Skills- Please list computer software packages that you can proficiently use:
Office Applicants- Please indicate skills and speed where appropriate: Reception Console
10-Key Adding
Typing
Typing- Words Per Minute
The following several questions are for nursing assistant applicants. Only answer them if they apply to you. How many hours was the Nursing Assistant training that you completed?
When did you complete the training? (month/day/year)
Have you taken the State test for Nursing Assistants? Yes
No
If yes, did you pass the test? Yes
No
If no, when do you plan to take or retake the test?
Did you receive a certification with the State Seal on it? Yes
No
Have you filled out an application to the Minnesota State Nursing Assistant Registry? Yes
No
Have you received a letter of acceptance to the Minnesota State Nursing Assistant Registry? Yes
No
If you are on the registry in another state, have you applied for reciprocity? Yes
No
If yes, when (month/day/year)
Professional references- If not previously employed, list personal references. Professional reference #1 Name-Title
Professional Reference #1 Business/organization
Professional Reference #1 Address
Professional Reference #1 Telephone
Professional Reference #1 Association with you
Professional Reference # 2 Name/Title
Professional Reference # 2 Business/Organization
Professional Reference # 2 Address
Professional Reference # 2 Telephone
Professional Reference # 2 Association with you
Professional Reference # 3 Name/Title
Professional Reference # 3 Business/Organization
Professional Reference # 3 Address
Professional Reference # 3 Telephone
Professional Reference #3 Association with you
How did you learn about this position? Posted job announcement
Friend or relative
Minnesota job bank
Classified Advertisement
Post Bulletin Ad
Job Fair
Other
By typing my electronic signature below, I promise that the information provided in this employment application is true and complete, and I understand that any false or misleading information or significant omissions may disqualify me from further consideration for employment, and may lead to my dismissal from employment, if discovered at a later date.
The information you provide in the following section will be used only to monitor our compliance with equal opportunity laws and regulations and for no other purpose. When we receive this form, we will immediately place it in a confidential file separate from your application. If you wish, you may mail this form to use in an envelope separate from the one that contains your application. The questions that follow pertain to the affirmative action form. Last Name
First Name
Date
Position you are applying for
As an affirmative action employer, we must monitor our equal employment opportunity and affirmative action program, and report the results to government agencies. Please help us gather this information by identifying your sex, race or ethnicity, and disability status on this form. Providing this information is completely voluntary. If you choose not to provide this information you will not be subject to any negative or adverse treatment. American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment
Asian: A person having origins in any of the original people of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American: A person having origins in any of the black racial groups of Africa.
Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
Disability- Are you a person with a disability? *This form is not used for employment decisions. If you have a disability and need an accommodation so that you can perform the duties of the job for which you are applying, please notify us in some other manner. Yes
No
Sex- Select One Female
Male
 

Copyright 2007 Samaritan Bethany Inc.