Employment Application Form

General Information

Full Name *

Date *

Current Address (required)




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Main Phone*:

Cell Phone:

Email Address*:

How Were You Referred To Braley Care Homes?

Employment Positions

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

Personal Information

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.)

Education, Training, And Experience

HIGH SCHOOL *

Did You Graduate? *
YesNo

UNDERGRADUATE COLLEGE

Course Of Study:

Years Completed:

Did You Graduate?
YesNo

Diploma/Degree:

GRADUATE / PROFESSIONAL COLLEGE

Course Of Study:

Years Completed:

Did You Graduate?
YesNo

Diploma/Degree:

VOCATIONAL SCHOOL

Course Of Study:

Years Completed:

Did You Graduate?
YesNo

Diploma/Degree:

Additional Information

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:

Work History

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

Personal/Professional References

(Do not include family members or past supervisors.)
 
Reference Name #1:

Phone Number

Association:
PersonalProfessional
 

Reference Name #2:

Phone Number

Association:
PersonalProfessional
 

Reference Name #3:

Phone Number

Association:
PersonalProfessional

Applicant Statement

- 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:

An Equal Opportunity Employer

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.