Bethany Health Care

Applicants for employment at Bethany Health Care Center, Inc. ("Bethany") are considered without regard to race, color, religion, sex, sexual orientation, age, genetic information, national origin, status as a Vietnam Era or disabled veteran or membership in the uniformed services, or physical or mental disability.
Position applied for *
Additional position applied for
Date
Referral Sources
 Advertisement 
 Website 
 School 
 Walk-in 
 Employee 
 Referral 
 Other 
If referred, name of referral source?
Name *
Prefix
First *
Last *
Suffix
Address *
City *
State *
Zip Code *
Phone Number *

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Cell Phone

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Email
Under age 18? *
 Yes 
 No 
If Yes, do you have a work permit?
 Yes 
 No 
Have you ever worked
at Bethany?
*
 Yes 
 No 
If Yes, please list time frame and position(s)
Type of Employment Desired *
 Full Time 
 Part Time 
Position Desired *
Shift Desired *
Salary Expected *
Date Available *
Willing to work weekends or holidays? *
 Yes 
 No 

Record of Education

Please complete each section that applies:
High School:
Please list location, year of graduation or number of years attended, and area of study
College:
Please list location, year of graduation or number of years attended, and area of study
Professional Trade:
Please list location, year of graduation or number of years attended, and area of study

Licensure / Certifications

Please list Type, State of Issue, License or Certificate Number and Expiration Date

Record of Employment

List below all present and past employment, beginning with your most recent position. You may include any verifiable work performed on a volunteer basis.
Company (most recent)
Start date
End date
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Supervisor Name
Phone Number

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May we contact this employer?
 Yes 
 No 
Your Job Title
Hourly rate / Salary
Type of Work Performed
Reason for leaving
Company (prior)
Start date
End date
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Supervisor Name
Phone Number

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May we contact this employer?
 Yes 
 No 
Your Job Title
Hourly rate / Salary
Type of Work Performed
Reason for leaving
Company (prior)
Start date
End date
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Supervisor Name
Phone Number

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May we contact this employer?
 Yes 
 No 
Your Job Title
Hourly rate / Salary
Type of Work Performed
Reason for leaving

References

Give the name and telephone number of three (3) business/work references who are not related to you. These may be from volunteer experiences.
Reference #1- please include address, telephone number and explain your connection
Reference #2- please include address, telephone number and explain your connection
Reference #3- please include address, telephone number and explain your connection

As part of Bethany's Organizational Integrity Program, all employment candidates must respond to the following question:

Have you ever been suspended, sanctioned or otherwise restricted from participating in any private insurance entity, federal, or state health insurance program (i.e., Medicare, Medicaid)?
*
 Yes 
 No 

Authorization & Terms of Understanding

I hereby declare that the information provided by me in this Application for Employment is true, correct and complete to the best of my knowledge. I authorize Bethany to investigate my past and present employment, education and activities and verify all data provided by me on this application on related papers and in interviews. I authorize all individuals, schools and/or firms named herein (except my current employer, if so noted) to provide any information requested about me. I release from all liability any persons, companies, corporations or educational institutions supplying such information. I release Bethany from any and all liability resulting from the verification of such information. I understand that any false statement or omission of fact on this application or on any supporting documents shall be grounds for non-hire or discharge, regardless of when discovered by Bethany.

I understand that, if I am hired by Bethany, my status will be that of an employee-at-will, meaning that I will have no contractual right, express or implied to remain in Bethany's employ. I further understand that, if I am hired by Bethany, my employment and compensation can be terminated with or without cause, and with or without notice, at any time, at the option of Bethany or me. I understand that no representative of Bethany has the authority to enter into any oral agreement for employment for a specified period of time or to make any agreement contrary to the foregoing.

I understand that, if I am extended an offer by Bethany, I will be required to provide evidence of my identity and authorization for employment in the United States prior to the commencement of my employment.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

I understand that, if I am hired by Bethany and my employment subsequently ends, Bethany may provide information about my employment to persons in response to job reference requests, and I hereby consent to such disclosures.
My submission indicates I have read and agree to the above Authorization & Terms of Understanding *
 Read and Agree