Employee Application Form

Bethany Lutheran Home for the Aged, Inc. is an equal opportunity provider and employer.

Are you C.N.A. Certified? *

Yes

No

Comment on C.N.A Certification (optional)

To which facility are you applying for? (you may select more than one) *

Bethany Home - Sioux Falls

Bethany Home - Brandon

Bethany Meadows Assisted Living - Brandon

Last Name: *

First Name *

Other Names? (optional)

Phone Number: *

Email Address: *

Confirm Email Address: *

Address: *

Education:

High School / GED Awarded from:

Please describe any postgraduate education you have and the date of graduation:

Please list any certifications you currently hold:

Employment History

Current Employer:

City, State

Employer Phone Number:

Start Date: (approximate)

End Date: (approximate)

Current Job Title:

Current Job Duties and Relevant Experience:

Reason for leaving?

Previous Employer (1)

Previous Employer:

City, State

Employer Phone Number:

Start Date: (approximate)

End Date: (approximate)

Job Title:

Job Duties and Relevant Experience

Reason for leaving?

May we contact this previous employer? (copy)

Yes

No

Previous Employer (2)

Previous Employer:

City, State

Employer Phone Number:

Start Date: (approximate)

End Date: (approximate)

Job Title:

Job Duties and Relevant Experience

Reason for leaving?

May we contact this previous employer?

Yes

No

Please list 3 references: Name, phone number, email address

Please list any final comments as to why you would be a good candidate for this position?

Applicants Statement: ( to be signed at interview)

Bethany Lutheran Home is committed to providing a drug and alcohol free environment. The use, possession, transfer or sale of illegal drugs or alcohol is not permitted on Bethany's property, either on or off duty. By my signature, I hereby give my consent to provide a urine sample or take a breath test to test for drugs and/ or alcohol, if requested by facility.

I further understand that any offer of, or continued employment is contingent upon:
Successful completion of a health assessment and drug test.
Satisfactory completion of reference checks with past employers and/ or personal references; and
Verification of current status with applicable licensing and certification authorities, when necessary.
Successful completion of a criminal background check.

Applicant's Signature Date

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Employment Application

Employee Application Form

Education:

Employment History

Previous Employer (1)

Previous Employer (2)