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Date*

Name*

First Middle Last

Position Applying For:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email

Gender*

Male
Female
I choose not to disclose this information

Ethnicity*

Hispanic or Latino (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race)
Not Hispanic or Latino (if not Hispanic or Latino, please address race below)
I choose not to disclose this information

Race*

White (Not Hispanic or Latino): a person having origins in any of the original peoples of Europe, the Middle East, or North Africa
Asian (Not Hispanic or Latino): a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam
American Indian or Alaska Native (Not Hispanic or Latino): a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment
Black or African American (Not Hispanic or Latino): a person having origins in any of the black racial groups of Africa
Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): a person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands
Two or More Races (Not Hispanic or Latino): all persons who identify with more than one of the above five races
I choose not to disclose this information

Protected Veterans*

I am a Protected Veteran
I am not a Protected Veteran
I choose not to disclose the information

The definitions of protected veterans are listed below. Use the boxes following the definitions to indicate whether you are a protected veteran. Disabled veteran: A "disabled veteran" is one of the following: 1) a veteran of the U.S. military, ground, naval, or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) a person who was discharged or released from active duty because of a service-connected disability. Recently Separated Veteran: A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service. Active Duty Wartime or Campaign Badge Veteran: An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval, or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. Armed Forces Service Medal Veteran: An "armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military , ground, naval, or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Voluntary Self-Identification of Disability

Yes, I have a disability (or previously had a disability)
No, I don't have a disability
I don't wish to answer

WHY ARE YOU BEING ASKED THIS QUESTION? Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities (Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligation of Federal contractors, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.) To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. Any answer you give will be kept private and will not be used against you in any way. HOW DO I KNOW IF I HAVE A DISABILITY? You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limit a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are limited to: blindness, deafness, cancer, diabetes, epilepsy, autism, cerebral palsy, HIV/AIDS, schizophrenia, muscular dystrophy, bipolar disorder, major depression, multiple sclerosis (MS), missing limbs or partially missing limbs, post-traumatic stress disorder (PTSD), obsessive compulsive disorder, impairments requiring the use of a wheelchair, intellectual disability (previously called medtal retardation). REASONABLE ACCOMMODATION NOTICE: Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

How did you learn of this opportunity:

Website/Facebook
Employee referral
Newspaper
Job Board (i.e., Indeed.com)
Other

Are you available to work:*

Full time
Part time
On Call

What shift are you available:*

Day
PM
Night

Have you been employed by Bethel Home and Services in the past?*

Yes
No

If yes, list dates of employment:

Are you legally eligible for employment in the United States?*

Yes
No

Proof of citizenship or immigration status will be required upon employment.

Have you ever been convicted of abusing, neglecting or mistreating individuals?*

Yes
No

In compliance with Federal regulations 42 CFR 483.13 (c)(1)(ii) and State statute (s.111.335(1)(c)(1).

Do you have pending charges or have you been convicted of a crime substantially related to the position for which you are applying?*

Yes
No

A criminal record does not necessarily disqualify an applicant from employment.

If you answered "yes" to the above question, please explain:

Please list any education relevant to the position for which you are applying:

Please list any licensure or certifications relevant to the position for which you are applying:

What makes you a great candidate?

Summarize special job-related skills & qualifications acquired from employment or other experiences.

Employment Experience #1*

Start with your present or last job. Include name of employer, dates of employment, work performed, and reason for leaving.

Employment Experience #2

Employment Experience #3

If you need additional space for employers, please list them in the general comments section below.

Name of Reference #1*

Please list 3 personal or professional references. Do not list relatives.

Phone number of Reference #1:

Name of Reference #2:*

Phone of Reference #2:*

Name of Reference #3:*

Phone of Reference #3:*

General Comments

Please use this section to include any other information you would like us to know about you in regard to this application for employment.

Signature of Applicant*

By typing my name I certify that all of the information is true and correct, and Bethel Home & Services, Inc. has my permission to request and obtain information relating to my criminal record and references.

Employment Application