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Were you previously employed by Bethany?*

If so, when?

Are you eligible to work in the United States?*

If you have ever been employed or attended school under another name, list other name(s) used:

Are you at least 16 years of age?*

Do you have an Employment & Age Certificate?

Have you ever performed Nurse Assistant duties or been listed on a state registry and/or licensing board?

In order to check Abuse Registries, please list all states in which you have been registered

Have you ever been convicted of an offense (including felonies and misdemeanors i.e. DUIs, insufficient funds, minors in consumption and convictions removed from record), excluding minor traffic violations?*

Explain

Have you ever been found guilty by a court of law of abusing neglecting or mistreating a resident or of misappropriate of their property?*

Explain. Include dates, places, charges, and results. Disclosure of information will not necessarily bar you from consideration for employment and will only be considered in relation to specific job requirements. Age and time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into consideration. Under federal regulations, however, conviction of resident abuse, neglect or mistreatment or misappropriation of resident property will disqualify you from consideration for employment.

For anyone who has worked as a CNA: Have you ever had a nurse aide registry listing or certification marked for abuse or negligence?

For anyone who has worked as a RN or LPN: Have you ever been investigated by a Board of Nursing?

Education & Licenses

Currently Enrolled In:

High School

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CNA Class

Not Enrolled

Did you graduate?

If required for this position, indicate License, Registration, or Certification Information (Ex: CNA, RN, LPN, Pharmacy, etc.)

Type

License Address

State

Number

Expiration Date

CNAs: If still in class, when is your test date?

Work Experience

Beginning with your most present or most recent employment (regardless of length of time), list all periods of employment and unemployment including military service assignments and volunteer activities.

Previous Employment

Company 1*

Company

Supervisor's Name & Title

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From

To

Your Title

Description of Duties

Reasons for Leaving

Ending Salary

If currently employed, may we contact them?

Company 2

Company

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To

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Ending Salary

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Would you like to add more Previous Employers?

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Company 3

Company

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Company Address

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Your Title

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Ending Salary

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Would you like to add more Previous Employers?

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Company 4

Company

Supervisor's Name & Title

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Your Title

Description of Duties

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Ending Salary

If currently employed, may we contact them?

Would you like to add more Previous Employers?

Yes

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More Previous Employers

Company

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Address

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Start & End Date

Title & Description

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Ending Salary

Personal Reference 1*

Name

Phone Number

How does this person know you?

Personal Reference 2

Name

Phone Number

How does this person know you?

I certify that answers given herein are true and complete to the best of my knowledge. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I further understand that I am required to abide by all rules and regulations of the facility.

Signature of Applicant

Bethany Retirement Living is an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, sexual orientation, gender identity, protected veteran status, or any other characteristic protected by law.

Bethany Retirement Living is an Equal Opportunity Employer
201 University Dr. S., Fargo, ND 58103
(701) 239-3000

APPLICANT DISCLOSURE AND RELEASE FOR BACKGROUND CHECKS, DRUG SCREENING, AND REFERENCE INFORMATION

Having made application for employment with Bethany Retirement Living, and desiring them to be informed as to my previous record and character, I hereby authorize Bethany Retirement Living and its authorized representatives to obtain information relating to my activities from educational institutions, licensing agencies and all persons or entities named on my employment application. This information may include, but is not limited to, academic, achievement, performance, attendance, personal history, discipline and conviction records. I hereby direct you to release such information upon the request of the bearer.

Further, I release any and all individuals and organizations, including record custodians, from and and all liability for damages of whatever kind or nature because of furnishing said information.

In connection with my application for employment with Bethany Retirement Living, I also understand that background checks will be performed on me if I receive an offer of employment from Bethany Retirement Living. I understand that an offer of employment is conditional on the results of the background information. The background information will be obtained through:

ADVANTAGE CREDIT BUREAU
5050 47th St S, Fargo, ND 58102
Toll free phone: 1-800-568-4478 / Fax: 701-239-9963

I understand the information obtained from a background check my include my past employment history, criminal history and driving record. I further understand that the background information is not limited to the current state of my residence, but may include information from any other state where I have resided.

I authorize all persons and companies contacted by the employer or its representatives to provide the requested background information. I understand and agree to release the aforesaid from any liability for collecting my background information.

I understand that if adverse action is taken by Bethany Retirement Living based on the results of my criminal background check, I will be given notice orally, in writing, or electronically of such adverse action. I further understand that I may request in writing within a reasonable period of time, a complete disclosure of the nature and scope of the background investigation. I also understand that I have the right to dispute the accuracy or completeness of any information furnished by the reporting agency. I further understand that the reporting agency supplying the information does not make the decision to take adverse action and cannot give specific reasons for the adverse action, only the employer makes such a decision.

I further authorize Bethany Retirement Living, if I am hired, to request a background report about me, for employment related purposes, at any time during the course of my employment to the extent allowed by law. I agree that this Disclosure and Release will be valid, now or in the future, in original, faxed, copied, or electronic form.

I also give my consent to Bethany Retirement Living and to Sanford Laboratory to perform the appropriate test(s) to identify the presence of drugs and/or alcohol. I furthermore give my permission for the test results to be released to Bethany Retirement Living. I understand that refusal to take this test, attempts to adulterate the sample, or a positive test may result in Bethany Retirement Living removing my application from consideration. In addition, I understand that Bethany Retirement Living does not allow smoking on its property.

Name*

First Middle Last

Last 4 of Social

Any other name(s) used*

Have you lived anywhere else in the last 7 years

Yes

No

Previous Address

Street Address City State / Province / Region ZIP / Postal Code

Previous Cities/States of Residence during last 7 years

Voluntary Self-Identification of Disability

Why are you being asked to complete this form?

We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years. Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

How do you know if you have a disability?

A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:

Blindness
Autism
Bipolar disorder
Post-traumatic stress disorder (PTSD)
Deafness • Cerebral palsy
Major depression
Obsessive compulsive disorder
Cancer • HIV/AIDS
Multiple sclerosis (MS)
Impairments requiring the use of a wheelchair
Diabetes
Epilepsy
Schizophrenia
Muscular dystrophy
Missing limbs or partially missing limbs
Intellectual disability (previously called mental retardation)

Please Select One of the Following*

Yes, I have a disability, or have had one in the past

No, I do not have a disability and have not had one in the past

I do not want to answer

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.

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Electronic Signature*

By signing this Electronic Signature Acknowledgment, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

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Education & Licenses

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