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 Last

E-mail Address:*

Your Location:*

City State

Phone:*

Age:

Check here if you are under 18 years old

Are you related to an employee or resident here?*

Yes
No

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

If yes, please 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

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: Heather Reich, Associate Administrator 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

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

Work Schedule Desired:*

Full Time
Part Time

Highest Level of Education:*

Year of Graduation:*

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

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 made any misrepresentations.

Phone

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

Employment Application