Bethany Health Care
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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.
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| Position applied for
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| Additional position applied for
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| Date
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| Referral Sources
| Advertisement Website School Walk-in Employee Referral Other
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| If referred, name of referral source?
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| Name
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| Address
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| City
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| State
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| Zip Code
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| Phone Number
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| Cell Phone
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| Email
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| Under age 18?
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| Yes No
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| If Yes, do you have a work permit?
| Yes No
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Have you ever worked
at Bethany?
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| Yes No
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| If Yes, please list time frame and position(s)
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| Type of Employment Desired
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| Full Time Part Time
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| Position Desired
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| Shift Desired
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| Salary Expected
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| Date Available
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| Willing to work weekends or holidays?
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| Yes No
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Record of Education
Please complete each section that applies:
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High School:
Please list location, year of graduation or number of years attended, and area of study
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College:
Please list location, year of graduation or number of years attended, and area of study
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Professional Trade:
Please list location, year of graduation or number of years attended, and area of study
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Licensure / Certifications
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| Please list Type, State of Issue, License or Certificate Number and Expiration Date
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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.
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| Company (most recent)
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| Start date
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| End date
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| Address
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| Supervisor Name
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| Phone Number
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| May we contact this employer?
| Yes No
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| Your Job Title
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| Hourly rate / Salary
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| Type of Work Performed
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| Reason for leaving
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| Company (prior)
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| Start date
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| End date
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| Address
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| Supervisor Name
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| Phone Number
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| May we contact this employer?
| Yes No
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| Your Job Title
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| Hourly rate / Salary
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| Type of Work Performed
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| Reason for leaving
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| Company (prior)
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| Start date
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| End date
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| Address
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| Supervisor Name
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| Phone Number
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| May we contact this employer?
| Yes No
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| Your Job Title
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| Hourly rate / Salary
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| Type of Work Performed
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| Reason for leaving
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References
Give the name, address and telephone number of three (3) business/work references who are not related to you and are not previous employers.
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| Reference #1- please include address, telephone number and explain your connection
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| Reference #2- please include address, telephone number and explain your connection
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| Reference #3- please include address, telephone number and explain your connection
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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)?
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| Yes No
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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.
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| My submission indicates I have read and agree to the above Authorization & Terms of Understanding
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| Read and Agree
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