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Braley Care Homes 6192 US 60 Hurricane, WV 25526

Employment

Application Form

Employment Application

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.

Applicant Information

First Name *

Last Name *

Home Phone *

Cell Phone Number *

Email *

Address *

How were you referred to Braley Care Homes? *

Employment Positions

Position(s) applying for: *

Are you applying for (check all that apply): *

Regular full-time work

Regular part-time work

Temporary work

What days and hours are you available for work? *

If hired, date available to start work? *

Starting salary desired: *

Personal Information

Have you ever applied to/worked for Braley Care Homes before? *

Yes

If yes, please explain (include date):

Do you have any friends or relatives working for Braley Care Homes? *

Yes

If yes, state name & relationship:

If hired, would you have transportation to/from work? *

Yes

Are you over the age of 18? (If under 18, hire is subject to verification of minimum legal age.) *

Yes

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? *

Yes

Are you able to perform the essential functions of the job for which you are applying, either with / without reasonable accommodation? *

Yes

If no, describe the functions that cannot 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)? *

Yes

If yes, please describe the crime - state 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:

School name: *

School city, state: *

Number of years completed: *

Did you graduate? *

Yes

College / University:

ii. School name: *

ii. School city, state: *

ii. Number of years completed: *

ii. Did you graduate? *

Yes

Degree earned: *

Vocational School:

iii. School name:

iii. School city, state

iii. Did you graduate?

Yes

Degree / diploma:

Additional Information

Do you speak, write or understand any foreign languages? *

Yes

If yes, which languages(s) and how fluent do you consider yourself to be.

Other experience, training, qualifications, or skills which you feel make you especially suited for working with us

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.

i. Employer

i. Address

i. Phone

i. Job Title

i. Supervisor

i. Reason for leaving

Dates Employed

i. From

i. To

Hourly rate/salary

i. starting

i. final

i. Work Performed

i. May we contact?

Yes

----------

ii. Employer

ii. Address

ii. Phone

ii. Job Title

ii. Supervisor

ii. Reason for leaving

Dates Employed

ii. From

ii. To

Hourly rate/salary

ii. starting

ii. final

ii. Work Performed

ii. May we contact?

Yes

---------

iii. Employer

iii. Address

iii. Phone

iii. Job Title

iii. Supervisor

iii. Reason for leaving

Dates Employed

iii. From

iii. To

Hourly rate/salary

iii. starting

iii. final

iii. Work Performed

iii. May we contact?

Yes

Personal/Professional References

Do not include family or past supervisors

i. Name

i. Phone #

i. Personal / Professional (Check One)

Personal

Professional

ii. Name

ii. Phone #

ii. Personal / Professional (Check One)

Personal

Professional

iii. Name

iii. Phone #

iii. Personal / Professional (Check One)

Personal

Professional

Applicant’s 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 SS# are: *

my nursing license # is *

Signature of Applicant *

Clear

Date *