Apply - Methodist Village

Date *

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Social Security # *

Position(s) applied for *

How did you hear about us? *

Best time to contact you at the number provided is: *

Have you ever applied with us? *

If yes, give approximate date: *

Do any friends or relatives work here? *

If yes, please state name, relationship, and department: *

Are you currently employed? *

May we contact your current employer? *

Do you have reliable transportation? *

Have you ever been charged or convicted of a misdemeanor/felony?

If yes, please give date and explanation: *

Are you prevented from lawfully becoming employed in this country because of Visa or immigrant status? *

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

Date available for work *

What is your desired salary range? *

When are you available to work? Full Time (Please indicate shift) *

Part Time Availability *

Methodist Village Senior Living has staffing standards that must be met by State and Federal Regulations. Our policy states that four absences a year is excessive, do you agree and/or are you able to adhere to our policy? *

Education

Please list the name of the high school you attended.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Address of the high school you attended.

Course of Study and Years Completed

If not applicable, please put NA.

Diploma/Degree *

Undergraduate College

Please list the name of the college you attended for undergraduate studies.

Address (Undergraduate College)

Address Line 1

Address Line 2

City

State

Zip Code

Course of Study and Years Completed *

Diploma/Degree *

Graduate/Professional

Please list the name the school attended for Graduate/Professional studies.

Address (Graduate school)

Address Line 1

Address Line 2

City

State

Zip Code

Course of Study and Years Completed *

Diploma/Degree

Other (Specify)

State Licensure

How long?

Where?

Work Experience-Employer Name *

Starting with your most recent job, include work experience, any job-related military service assignments, and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.

Date Employed From *

Date Employed To *

Work Performed *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Supervisor Name: *

Job Title *

Starting Hourly/Salary Rate *

Final Hourly/Salary Rate *

Reason for leaving *

May we contact? *

Employer Name

Date Employed From

Date Employed To

Work Performed

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Supervisor Name:

Job Title

Starting Hourly/Salary Rate

Final Hourly/Salary Rate *

Reason for leaving

May we contact?

Employer Name

Starting with your most recent job, include work experience, any job-related military service assignments, and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.

Date Employed From

Date Employed To

Work Performed

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Supervisor Name:

Job Title

Starting Hourly/Salary Rate

Final Hourly/Salary Rate *

Reason for leaving

May we contact?

Personal References *

Include Name, Relationship, and phone number

Comments

Include explanation of any gaps in employment.

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. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by the applicable law, any employment relationship with this organization is an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with our without cause. It is further understood that this "at will" employment may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview may result in discharge. I understand; also, that I am required to abide by all rules and regulations of the employer. *

Please enter your first and last name for your signature.

Today's Date *

Employment Reference Consent and Release: I hereby give consent to prior employers of mine to provide information about my employment with prior employers to prospective employers. By signing this consent, I am voluntarily requesting that the prior employer respond to reference requests from Methodist Village Senior Living. I authorize the prior employer to disclose any employment-related information that may include: • Date and Duration of employment • Current pay rate and wage history • Job descriptions and duties • The last written performance evaluation prepared prior to the date of request • Attendance information • Results of drug or alcohol test administered within one year prior to request • Threats of violence, harassing acts, or threatening behavior related to the workplace of directed at another employee • Whether the employee was voluntarily or involuntarily separated from employment and the reasons for separation. • Whether the employee is eligible for rehire RELEASE: I hereby release and discharge the prior employer and the prior employer’s successors, officers, directors, and agents for all claims, liabilities, and cause of action known or connected to its disclosure of employment – related information to a prospective employer. This misrepresentation, and interference with contract or profession. I have carefully read and fully understand the provisions of this release. I acknowledge that I was given the opportunity to consult with an attorney and other individuals of my choosing before signing this release and that I have decided to sign this release voluntarily and without coercion or duress by any person. This release sets forth the entire agreement between the prior employer and me, and I acknowledge that I have not relied upon any representation of statement, written or oral, not set forth in this document. Instructions for Current/Former Employer: Please respond candidly to the requests for information listed below and return your written response via fax, e-mail, or mail. Methodist Village Senior Living Att. Human Resources Department 7811 Euper Lane Fort Smith, AR 72903 hr@methodistvillage.com

Please enter your first and last name for your signature.

Employment Questionnaire-Nursing Department Only

Please answer the following questions to the best of your ability.

How would you handle a situation where you are trying to work with a resident and they are mad or yelling at you?

What do you think you could bring to this facility to help maintain acuity of care?

What would you do if you found a resident on the floor?

Give an example of a time when you went above and beyond the call of duty.

Understanding the facility need for overtime, are you willing to comply?

Give an example of your ability to motivate a resident when they don't want to take a bath.

What does the term teamwork mean to you?

Give an example of your ability to work as a team.

Give an example of a time you were able to successfully communicate with another co-worker even though there was a past conflict.

How would you define success as a CNA?

Name *

First

Last

By entering your first and last name, you are acknowledging this as a signature for the completed form.