Birchaven Village Application
Position(s) Applied For Date of Application
     Date of Application
3/11/2010 5:57:10 AM
Name     Last
        First
    Middle
     Former Name(s)
Current Address No. and Street
     City
     State
     Zip Code
Permanent Address No. and Street
     City
     State
     Zip Code
Social Security No. (last four digits) Email Address 
Home Telephone No.
(Area Code) 		    Work Phone  
(Area Code) 		    Other No.  
(Area Code)
Are you available to work:     Full Time     Part Time     Casual     Temporary     On Call
Are you currently on "lay-off" status and subject to recall?     Yes     No
Are you currently employed?     Yes     No     Date Available? 
mm/dd/yy
Have you ever been employed with us before?     Yes     No     Department 
Do you have relatives who work here?     Yes     No     Relative Name/Relationship 
Are you available to work on weekends?     Yes     No
If you are under 18 years of age, can you provide required proof of your eligibility to work?     Yes     No
Have you ever filed an application with us before?     Yes     No
If Yes, when? 
Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?
Proof of citizenship or immigration status will be required upon employment. 		    Yes     No
Have you been convicted of a felony within the last 7 years?
Conviction will not necessarily disqualify an applicant from employment.		     Yes     No
If Yes, please explain
Are you excluded from participation in any federal health-care program including medicare, medicaid, and CHAMPUS?     Yes     No
We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, or disability, or any other legally protected status.
Employment Application
EDUCATION
  Elementary High School Specialty School College Graduate
Highest Year
Completed 
1
 2
 3
 4
 5
 6
 7
 8
9
 10
 11
 12
1
 2
 3
 4
1
 2
 3
 4
1
 2
 3
 4
Type School Name and Address of School Diploma or Degree? Major Specialty
Elementary
or
High School		 Name Yes    No
Street
City, State Type 
College Name Yes    No
Street
City, State Type 
Other:
Specify		 Name Yes    No
Street
City, State Type 
Other:
Specify		 Name Yes    No
Street
City, State Type 
Are you currently enrolled in an educational program? Yes No     Any hours when not available?
If so, what is your main course of study?
Special Skills and Qualifications

Summarize special job-related skills and qualifications acquired from employment or other experience.

Have you had current education and/or experience in Medical Terminology? Yes No
PROFESSIONAL LICENSES AND REGISTRATIONS
Type     Reg. No.     Date Expires 
mm/dd/yy		    State 
EMPLOYMENT EXPERIENCE
Start with your present or most recent job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disability, or other protected status.

Employer  Length of Service Work Preformed
Address  From: 
mm/dd/yy
Telephone Number(s)  To: 
mm/dd/yy
Job Title Supervisor Hourly Rate/Salary
Reason for Leaving  Starting
 Final

Employer  Length of Service Work Preformed
Address  From: 
mm/dd/yy
Telephone Number(s)  To: 
mm/dd/yy
Job Title Supervisor Hourly Rate/Salary
Reason for Leaving  Starting
 Final

Employer  Length of Service Work Preformed
Address  From: 
mm/dd/yy
Telephone Number(s)  To: 
mm/dd/yy
Job Title Supervisor Hourly Rate/Salary
Reason for Leaving  Starting
 Final

Employer  Length of Service Work Preformed
Address  From: 
mm/dd/yy
Telephone Number(s)  To: 
mm/dd/yy
Job Title Supervisor Hourly Rate/Salary
Reason for Leaving  Starting
 Final

List Other Previous Employers
Name Address Dates Reason for Leaving
May we contact all the employers listed? Yes     No
If not, indicate which one(s) you do not want contacted:
PERSONAL/PROFESSIONAL REFERENCE
Name and Occupation Address Home Phone No. Work Phone No.
Applicant’s Statement

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employ-ment as may be necessary in arriving at any employment decision.

This application for employment shall be considered active for a period of time not to exceed 6 months. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

The applicant understands that neither this document nor any offer of employment from the employer constitutes an employment contract unless a specific document to that affect is executed by the employer and associate in writing.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

I understand that if employed, I can terminate my employment relationship with the Birchaven Village at any time and for any reason, and Birchaven Village has the same right.

REQUIRED: By checking this box I agree to the above terms.

The health care environment requires staffing 7 days per week, 365 days per year, which includes weekends and holidays. Regardless of the position for which you are hired, schedules (hours, weekends, holidays, and call situations) are subject to change.