Bethany Lutheran Home

Employment Application

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.

*(Fields marked with are required.)** * Position applied for * How did you learn about us?
Advertisement	Relative	Inquiry
Employment Agency	Friend	Other

* Last Name
* First Name
* Middle Name
* Address
* City
* State
* Zip Code
* Telephone Number
E-Mail Address

* If you are under 18 years of age, can you provide required proof of your eligibility to work?			Yes No
* Have you ever filed an application with us before?			Yes No
If Yes, give date. / /
* Have you ever been employed with us before?			Yes No
If Yes, give date. / /
* Do any of your friends or relatives, other than spouse, work here?			Yes No
* Are you currently employed?			Yes No
* May we contact your present employer?			Yes No
* Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment.			Yes No
* Date available for work: / /
* What is your desired salary range?
Are you available to work:			Full-Time (please indicate shift) 1 2 3
			Part-Time (please indicate time) Morning Afternoon Evening
			Temporary (please indicate dates) / / to / /
* Are you currently on "lay-off" status and subject to recall?			Yes No
* Can you travel if a job requires it?			Yes No

EDUCATION
High School/GED:
Name and Address of School:
Course of Study:
Number of Years Completed:
Did you graduate?	Yes
	No
	Not Applicable
Undergraduate College:
Name and Address of School:
Course of Study:
Number of Years Completed:
Did you graduate?	Yes
	No
	Not Applicable
Other (Specify):
Name and Address of School:
Course of Study:
Number of Years Completed:
Did you graduate?	Yes
	No
	Not Applicable

Describe any specialized training, apprenticeship, skills, and extra-curricular activities.

Describe any job-related training received in the United States military.

EXPERIENCE:
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Employer #3
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