Beachwood Pointe Employment Application

BEACHWOOD POINTE EMPLOYMENT APPLICATION

Directions:
Respond to ALL questions. If a particular question does not apply to you, or the position for which you are applying, write N/A in the appropriate space. PLEASE PRINT CLEARLY. Incomplete applications will not be considered.

EQUAL OPPORTUNITY EMPLOYER: Provider Services, Inc. will not discriminate against any employee or applicant for employment because of race, color, religion, sex, age, national origin, ancestry, citizenship status, disability, handicap or any other legally protected category. Any information about the applicant will not be used for impermissable purposes.

PERSONAL

Last Name First Name M.I.

Address City

State Zip Code

Home Phone Alternate Phone

How did you hear of job opening?

Are employment records pertaining to you kept under any other name? Yes No
If yes, what name

If under 18 years of age, do you have a work permit?
Yes No

In Case of Emergency notify:
Name Telephone

POSITION DESIRED

Position Applied For:
(Be Specific)

Salary Expected: $
Per Hour Annually

Date Available:

Shifts Preferred:

Day Evening
Night No Preference

Full-Time Part-Time
PRN/Per Diem Temporary

Days Preferred:

Are you willing to work weekends?
Yes No

SUN MON TUES WED THURS FRI SAT

LICENSE OR CERTIFICATION

Type

State

Date Received

Last Renewal

Certificate Number

By
Examination

By
Reciprocity

EDUCATION

Are you attending school now? Course of Study
Yes No

Last year of school completed:

College/Graduate: Nursing: Business/Trade:

High School

City/State

Graduate
Yes No

Degree

Grade Pointe Average

College or Nursing

Graduate
Yes No

Degree

Grade Pointe Average

Business or Trade

Graduate
Yes No

Degree

Grade Pointe Average

Please check the box that best describes your attendance
at your most recent place of employment: Excellent Good Average

WORK HISTORY (Record Uniformed Service as a Position)

List names of all present and former employers, beginning with the most recent. Explain gaps in employment.

Position Title

From To

Employer

Phone

Address

City

State Zip Code

Position Responsibilities

Reason for Leaving

Name & Title of Immediate Supervisor

Starting & Ending Salary

Beginning Pay Rate
$ per hour or

$ per year

Ending Pay Rate
$ per hour or

$ per year

Position Title

From To

Employer

Phone

Address

City

State Zip Code

Position Responsibilities

Reason for Leaving

Name & Title of Immediate Supervisor

Starting & Ending Salary

Beginning Pay Rate
$ per hour or

$ per year

Ending Pay Rate
$ per hour or

$ per year

Position Title

From To

Employer

Phone

Address

City

State Zip Code

Position Responsibilities

Reason for Leaving

Name & Title of Immediate Supervisor

Starting & Ending Salary

Beginning Pay Rate
$ per hour or

$ per year

Ending Pay Rate
$ per hour or

$ per year

Position Title

From To

Employer

Phone

Address

City

State Zip Code

Position Responsibilities

Reason for Leaving

Name & Title of Immediate Supervisor

Starting & Ending Salary

Beginning Pay Rate
$ per hour or

$ per year

Ending Pay Rate
$ per hour or

$ per year

May we contact your present employer? Yes No

NOTICE: I understand that this employment application and any other Company documents are not contracts of employment, express or implied, and that if hired, I may voluntarily leave employment, or be terminated by the Company at anytime for any and/or no reason, with or without cause. I understand that any written or oral statements to the contrary are hereby expressly disavowed and will not be relied upon by me. I give the Company and its agents permission to enter the information I provide on this application into an electronic information system used by the Company.

The information given by meis certified to be true and complete for all practical purposes and it may be verified by Provider Services, Inc. Should a position be offered and later it is found that the information is untrue, incomplete or misrepresented, I understand and agree that Provider Services, Inc. is relieved of all commitments, financial or otherwise, pertinent to employment, and that I am subject to immediate discharge without recourse. I also understand that my employment is dependent upon my supplying proof that I am authorized to work in the United States. It is further understood that I may be offered employment conditioned on my successfully passing criminal and/or other background checks and/or drug test and/or physical exam to the satisfaction of the Company.

Provider Services, Inc. is required by law to ask the following questions and may be required by law to report the answers to governmental agencies responsible for supervising healthcare, nursing home, home care and/or hospice care activity:

Have you ever been convicted and/or been found guilty by a court of competent jurisdiction or a state agency of abusing, neglecting or mistreating residents or of misappropriating resident property in this state or in any other state? If so, please describe the offense, the date and place of the conviction, and the underlying circumstances or any other information to help us evaluate your current fitness for employment.

No Yes Explain:

Have you ever been convicted of a felony? If so, please describe the offense, the date of the conviction and the underlying circumstances or other information to help us evaluate your current fitness for employment:

No Yes Explain:

Have you ever been convicted of (1) cruelty to persons or (2) assault of a victim 60 years of age or older? If so, please describe the offense, the date of the conviction and the underlying circumstances or other information to help us evaluate your current fitness for employment:

No Yes Explain:

Have you ever been sanctioned by a health care licensing agency in this or any other state, or in any other United States or Foreign jurisdiction? If so, please identify the nature and date of the action, the licensing agency involved and the underlying circumstances or other information to help evaluate your current fitness for employment.

No Yes Explain:

“I hereby certify that I have not been convicted and/or found guilty of resident or patient abuse, neglect or mistreatment, or of misappropriation of resident or patient property in this state or in any other state, and that I am not listed in any resident or patient abuse registry in this state or in any other state. I understand that any offer of employment that is extended to me by a provider Services, Inc. location is conditional upon the verification of this information with the state patient abuse registry and that a listing in such registry or the registry of any other state may act as an automatic withdrawal of any such offer of employment.”

“I further understand that if I’m applying for a licensed or certified position, any offer of employment by a Provider Services, Inc. location is conditional upon verification of my license or certification with the appropriate state agency. In the event that I have not yet been so licensed or certified and in the event that I am offered employment with Provider Services, Inc., I agree to undertake the required training and competency certification requirements immediately upon commencing employment.”

INVESTIGATION INFORMATION RELEASE AUTHORIZATION

I understand that Provider Services Inc. requires a thorough pre-employment background investigation. This investigation is limited to only that information required to determine fitness for employment and may include, but not limited to: employment history verification, job performance, disciplinary record, financial/credit history and a criminal background investigation. By signing this agreement, I agree to hold harmless any previous employer, agent of that corporation, or any individual or organization providing information pursuant to this authorization.