Community at Brookmeade Application | Community at Brookmeade

Order Number

Instructions:

We appreciate your interest in our organization. A clear understanding of background and work history will help us place you in a mutually beneficial job position. We consider applicants for all positions without regard to race, color, creed, age, gender, sexual orientation, disability, marital status, military or veteran status, arrest/conviction record, national origin, genetic information, predisposition, or carrier status, domestic violence victim status or any other status protected by applicable law.

Please Check: *

Arbor Ridge The Terraces The Baptist Home

Position: *

Date available *

Salary Requirements $/Hour *

Personal Information

Name *

Email *

Mailing Address *

City *

State *

Zip Code *

Last 4 Digits of Soc. Sec. # *

Phone Number *

Home Cell

Any other name(s) under, which you have been previously employed:

Names of friends or relatives employed in this organization

If you are under 18 years of age, can you furnish a work permit? Have you ever been employed by us before? *

furnish a work permit?

Yes No

Are you legally allowed to work in the U.S.? *

allowed to work

Yes No

Are you able to perform the essential functions of the position for which you are applying, with or without reasonable accommodation?

with or without reasonable accommodation

Yes No

Have you ever been convicted of or pled guilty to a felony, misdemeanor, violation, or other crime (other than a minor traffic violation)?

Have you ever been convicted of or pled guilty

Yes No

Are there any arrests or criminal accusations pending against you?

arrests or criminal accusations

Yes No

Note: Neither a conviction nor an arrest is an automatic bar from employment. Each case is considered and evaluated on its individual merits in relation to the duties and responsibilities of the position.

Have you ever been sanctioned or otherwise disciplined by, or excluded from, the New York Medicaid Program, Medicare or any other state or federal government funded program?

Yes No

Are you available to work: *

Full Time Part Time Shift Work

Can you travel if the job requires it? *

Yes No

Are there any restrictions? *

Yes No

HIGH SCHOOL

School Name , Address And Phone Number

Course Of Study

Did you graduate from this institution?

COLLEGE

College Name , Address And Phone Number

Course Of Study

Did you graduate from this institution?

TECHNICAL, BUSINESS TRAINING

Name , Address And Phone Number

Course Of Study

Did you graduate from this institution?

OTHER (SPECIFY)

Name , Address And Phone Number

Course Of Study

Did you graduate from this institution?

Professional organizations and/or license(s) that may be job related:

Please attach copies of current professional certificates/licenses.

Have you ever been investigated by, or subject to a disciplinary proceeding by a professional licensure or disciplinary agency (such as the Office of Professional Discipline, the Office of Professional Medical Conduct, or the Department of Health), in New York or in any other state?

disciplinary proceeding by a professional licensure

Yes No

REFERENCES: Give name, address and a telephone number of three references not related to you who are qualified to evaluate your capabilities and are not previous employers.

References 1

References 2

References 3

Availability Form:

Please write below what times you would be available to work as well as times you are not available to be scheduled to work. These are required fields

Monday

Start

Finish

Tuesday

Start

Finish

Wednesday

Start

Finish

Thursday

Start

Finish

Friday

Start

Finish

Saturday

Start

Finish

Sunday

Start

Finish

Employment Experience

List below your last five employers, beginning with the most recent.
Please sign the two Employment Reference Checks that are attached to this application.

Employer #1 Name, Address And Phone Number (Most Recent First)

Position Title

From

Explain any break in employment between the position below and the position above:

Employer #2 Name, Address And Phone Number

Position Title

From

Explain any break in employment between the position below and the position above:

Employer #3 Name, Address And Phone Number

Position Title

From

Explain any break in employment between the position below and the position above:

Employer #4 Name, Address And Phone Number

Position Title

From

Explain any break in employment between the position below and the position above:

Employer #5 Name, Address And Phone Number

Position Title

From

Have you worked for us previously? *

Yes