Full Name *
Date *
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Main Phone*:
Cell Phone:
Email Address*:
How Were You Referred To Braley Care Homes?
Position(s) Applying For:
Applying For (check all that apply) Regular Full-Time WorkRegular Part-Time WorkTemporary Work
What Days And Hours Are You Available For Work?
Desired Start Date
Desired Start Salary
Have you ever applied to Braley Care Homes before?* YesNo
If Yes, Please Explain (include date):
Do You Have Any Friends Or Relatives Working For Braley Care Homes? * YesNo
If Yes, Please State Name And Relationship:
If Hired, Would You Have Transportation To / From Work? * YesNo
Are You Over The Age Of 18? (If under 18, hire is subject to verification of minimum legal age.) * YesNo
If Hired, Would You Be Able To Present Evidence Of Your U.S. Citizenship Or Proof Of Your Legal Right To Work In The United States? * YesNo
Are You Able To Perform The Essential Functions Of The Job For Which You Are Applying, Either With Or Without Reasonable Accommodation? YesNo
If No, Describe Functions That May Not Be Able To Be Performed:
(Note: Braley Care Homes complies with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional.)
Have You Ever Been Convicted Of A Criminal Offense (felony or misdemeanor)? * YesNo If Yes, Please Describe The Crime. Include The Nature Of The Crime(s), When And Where Convicted And Disposition Of The Case:
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)
HIGH SCHOOL *
Did You Graduate? * YesNo
UNDERGRADUATE COLLEGE
Course Of Study:
Years Completed:
Did You Graduate? YesNo
Diploma/Degree:
GRADUATE / PROFESSIONAL COLLEGE
VOCATIONAL SCHOOL
Do You Speak, Write Or Understand Any Foreign Languages? YesNo
If Yes, Which Language(s), And How Fluent Do You Consider Yourself To Be?
Describe Any Other Experience, Training, Qualifications, Or Skills Which You Feel Make You Especially Suited For Working With Braley Care Homes:
Start with last employment. Include job related military service or volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.
LAST/CURRENT EMPLOYER Address Dates Employed: From: To: Job Title Supervisor Describe Work Performed: Hourly Pay/Salary: Starting: Final: Reason For Leaving May We Contact? YesNo
PREVIOUS EMPLOYER Address Dates Employed: From: To: Job Title Supervisor Describe Work Performed: Hourly Pay/Salary: Starting: Final: Reason For Leaving May We Contact? YesNo
(Do not include family members or past supervisors.) Reference Name #1:
Phone Number
Association: PersonalProfessional
Reference Name #2:
Reference Name #3:
- I certify that answers given herein are true and complete. - I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. - In the event of employment, I understand that false or misleading information given in my application or interview(s) may resulting discharge. - I understand a criminal background check is required for employment, and that I will be responsible for the cost of the background check, and further if the results are not in compliance with WV State regulations I will be dismissed from employment immediately. - I understand it is mandatory to have a tuberculosis PPD test before the first date of employment. - I understand it is mandatory to have a current CPR/First Aid certification. Braley Care Homes will provide the class at no cost, and I must have this certification within 15 days of hire. - I understand the Alzheimer’s Dementia Training is required for employment at Braley Care Homes III. The training may be obtained by several mean, however is offered at no charge at Braley Care Homes III. Employment begins the first day of shadowing. You are not compensated for the Alzheimer’s Dementia Training. - I understand that the Nurse/Nurse Aid Abuse Registry check will be performed before beginning employment.
The Last Four Digits Of My Social Security Number Are: * My Nursing License Number Is:
Braley Care Homes is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Applicants requiring reasonable accommodation in the application and/or interview process should notify a representative of the organization.
© 2020 Braley Care Homes, Inc.