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

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.

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.

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.

Voluntary Information

As an affirmative action employer, we must monitor our equal employment opportunity and affirmative action program, and report the results to government agencies. Please help us gather this information by identifying your sex, race or ethnicity, and disability status on this form.
Providing this information is completely voluntary. If you choose not to provide some or all of this information, you will not be subject to any negative or adverse treatment.
The information you provide will be used only to monitor our compliance with equal opportunity laws and regulations and for no other purpose. When we have received this form, we will immediately place it in a confidential file separate from our application. If you wish, you may mail this form to us in an envelope separate from the one that contains your application.
This section is not used for employment decisions.

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