Bethesda Home of Goessel, Kansas

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Application for Employment

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.

Position(s) Applied For

Date of Application

How Did You Learn About Us?

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Employment Agency

Relative
Friend

Inquiry
Other:

Last Name:

First Name:

Middle Name

Email Address

Street Address:

City:

State:

Zip Code:

Telephone Number(s):

Best time to contact you at home is:

If you are 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 ever been employed with us before?
Yes No
If Yes, give date:

Do any of your friends of relatives, other than your spouse, work here?
Yes No

Are you currently employed?
Yes No

May we contact your present employer?
Yes No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
Proof of citizenship or immigration status will be required upon employment
Yes No

Date available for work:

What is your desired salary range?

Are you available to work:

Full-Time

1st shift
2nd shift
3rd shift

Part-Time

Mornings
Afternoons
Evenings

Temporary

Please indicate dates available:
From:
To:

Are you currently on "lay-off" status and subject to recall?
Yes No

Can you travel if a job requires it?
Yes No

Have you 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.

Education

	Name and Address of School	Course of Study	Number of Years Completed	Diploma Degree
Elementary School
High School
Undergraduate College
Graduate Professional
Other (Specify)

Describe any specialized training, apprenticeship, skills and extra-curricular activities.

Describe any job-related training received in the United States military.

Employment Experience

Start 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.

		From	To	Work Performed
Employer, address and phone number(s)		Dates Employed		Work Performed

		Hourly Rate/Salary
		Starting	Final
Job Title	Supervisor
Reason for Leaving

		From	To	Work Performed
Employer, address and phone number(s)		Dates Employed		Work Performed

		Hourly Rate/Salary
		Starting	Final
Job Title	Supervisor
Reason for Leaving

		From	To	Work Performed
Employer, address and phone number(s)		Dates Employed		Work Performed

		Hourly Rate/Salary
		Starting	Final
Job Title	Supervisor
Reason for Leaving

		From	To	Work Performed
Employer, address and phone number(s)		Dates Employed		Work Performed

		Hourly Rate/Salary
		Starting	Final
Job Title	Supervisor
Reason for Leaving

If you need additional space, please continue here:

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:

Additional Information

Other Qualifications
Summarize 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
Typing WPM
Shorthand WPM

Production/Mobile
Machinery (list)

Other (list)

State additional information you feel may be helpful to us in considering your application.

Note for Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Can you perform the essential functions of the job, for which you are applying, either with or without a reasonable accommodation?
Yes No

References

Please give the name, address, phone number and email address for all of your references.

Reference #1:

Reference #2:

Reference #3:

Applicant's Statement

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Signature of Applicant

Date

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