Work at Timbercrest

APPLICANT INFORMATION:

Please read carefully before completing the application for employment.

As a part of the employment process, Timbercrest will be requesting a criminal history of all persons offered employment.

Name:*

First Middle Last

E-mail Address:*

Your Location:*

Street Address City State ZIP Code

Phone:*

Alternate Phone:

Age:

Check here if you are under 18 years old

Are you related to an employee or resident at Timbercrest?*

Yes
No

Name(s):

Have you ever been convicted of a felony or of a crime (including but not limited to battery, neglect, exploitation, theft, etc.) substantially related to a dependent population?*

Yes
No

Explain:

Have you ever been notified by the Office of the Inspector General of HHS that you are excluded from working for facilities providing care to Medicare/Medicaid recipients?*

Yes
No

If yes, please explain:

NON-DISCRIMINATION STATEMENT

The Church of the Brethren Home, Inc. does not discriminate against any person on the basis of race, color, national origin, disability, or age in admission, treatment, or participation in its programs, services and activities, or in employment. For further information about this policy, contact: Director of Human Resources at (260) 982-2118.

Employment Desired:*

Please check all areas in which you are interested.

Food Service
Nursing
Housekeeping
Maintenance
Laundry
CNA Class
Other Departments

Desired Shift*

First
Second
Third

Are you willing to work weekends?*

Yes
No
Occasionally

If you selected "Other Departments", please indicate other area(s) of interest:

Work Schedule Desired:*

Full Time
Part Time

Highest Level of Education:*

Name of School:*

Employment History:*

Please enter at least your last two positions.

Past Position #1:

Name of Employer	Address of Employer	Start Date	End Date	Job Title	Salary	Reason for Leaving

Employment History:*

Past Position #2:

Click the

icon to add additional past positions beyond two.

Name of Employer	Address of Employer	Start Date	End Date	Job Title	Salary	Reason for Leaving

**Please indicate any employer you do not wish us to contact:

References:*

Please enter TWO references.

Reference #1:

Name	Email	Phone	Occupation

References:*

Reference #2:

Name	Email	Phone	Occupation

Attach a Resume (Optional)

If desired, attach a resume here.

Max. file size: 256 MB.

Certification:*

I certify that, to the best of my knowledge, all information given on this form is true, and I understand that I will be subject to discharge if I have made any misrepresentations. Further, I herby authorize Timbercrest, and also authorize and request each former employer and person, firm or corporation given as a reference (except those designated whom I request that you do not contact) to answer all questions that may be asked, and to give all information that may be sought in connection with this application or concerning me or my work, habits, character or skill, or my action in any transaction, and I hereby release them from any liability for damages on account of such information. I further understand that employment at Timbercrest is at will, and that acceptance of an offer for employment does not create a contractual agreement upon Timbercrest to continue to employ me in the future.

Name

This field is for validation purposes and should be left unchanged.

Nurse-Second Full Time or Part Time

Employment Application