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Employment Application
Nurse -Day Shift -Part Time
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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:
*
High School
Trade School
College
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: 512 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.