Employment Application Form

     

    General Information

     

    Full Name *

    Date *

    Current Address (required)




    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.
     
     

       

      General Information

       

      Full Name *

      Date *

      Current Address (required)




      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.
       
       

      Contact Us

      Location:

      Braley Care Homes

      6192 US 60

      Hurricane, WV 25526

       

      Phone Numbers:

      Referrals and Inquiries: (304) 767-4033

      Facility Phone: (304) 201-3677

      Facility Fax: (304) 201-3678

      © 2020 Braley Care Homes, Inc.