Name and Address

Full Name*

Phone*

Email*

Street*

City*

State*

Zip*

Additional Information

Have you ever been known by a different name?

YesNo

If yes, what was it?

Please explain

Have you ever been employed by Golden View?

YesNo

If "YES", department? Enter N/A if not applicable

Dates of Employment

Why did you leave?:

List any friends or relatives working for us

Name 1

Relationship 1

Name 2

Relationship 2

Position

What position are you applying for?

Salary Expectations

What are the two (2) most important factors to you in this position?

Important Factor #1 in this position

Important Factor #2 in this position

Work Schedule

What type of employment do you want? (check one)

Full-timePart-time

When could you start employment?

Shift desired?

What is the minimum # of hours you could consider acceptable per day?

Can you work a flexible schedule (days scheduled & number of hours scheduled is different every week)?

YesNo

What days & times are you available to work? Include a.m. or p.m.

Employment Status

Are you currently employed?

YesNo

If yes, how many jobs do you currently hold?

Is your intent to continue in your current job(s) if you work for Golden View?

Are you currently a student? (or planning to be within 6 months)

YesNo

If yes, what impact does this have on your availability for work?

Employment History

Have you ever worked in a health care center before?

YesNo

If yes, where?

If yes, what position did you hold and for how many years?

In the past 5 years, how many different employers have you worked for?

Employment Record

List most recent or present employer first. Include military service, or any self-employed or unemployed periods. Account for the past three (3) employers or past five (5) years or since completing school, whichever is more recent.Present or most recent employer

Company*

Company Address*

Company Phone*

Dates Employed*

Last Salary*

Last Position Held*

May we contact your present employer?

YesNo

Last Supervisor's Name*

Supervisor Contact Information*

Why did you leave?Be specific

Like MOST about the job?Be specific

Like LEAST about the job?Be specific

Employer 2

Company 2

Company 2 Address

Company 2 Telephone

Dates Employed at Company 2

Last Salary at Company 2

Last Position at Company 2

May we contact company 2?

YesNo

Last supervisor's name at company 2

Supervisor contact info at company 2

Why did you leave company 2Be specific

Like MOST about the job (2)?Be specific

Like LEAST about the job (2)Be specific

Employer 3

Company 3

Company 3 Address

Company 3 Phone

Dates employed at Company 3

Last Salary at Company 3

Last Position at Company 3

May we contact your previous employer (3)?

YesNo

Last supervisor's name at company 3

Supervisor's contact info at Company 3

Why did you leave company 3?Be specific

Like MOST about the job (3)Be specific

Like LEAST about the job (3)?Be specific

Education

Name of High SchoolIf you attended high school

High School City

Last year completed at high school:

Graduated high school?

YesNo

Name of college attendedIf you attended college

Last year completed in college

Graduated from college?

YesNo

Major course of study

DegreeIf applicable

Training & Licenses

Do you have any other kind of education/training?

YesNo

If yes, please describe

Do you have any professional licenses?

YesNo

If yes, what type and expiration date

Do you have a dementia training certificate?

YesNo

Are you legally authorized to work in the United States?

YesNo

Document NumberIf applicable

If hired, verification will be required consistent with Federal Law.

References

Give the names of 2 persons who are not relatives or former employers, who have known you for five (5) years or more.

Reference 1 Relationship

Reference 1 Name

Reference 1 Current Address

Reference 1 City/State/Zip

Reference 1 Telephone No.

Reference 1 Number of Years Known

Reference 2 Relationship

Reference 2 Name

Reference 2 Current Address

Reference 2 City/State/Zip

Reference 2 Telephone No

Reference 2 Number of Years Known

Referral Information

How were you were referred to Golden View?NewspaperEmployee ReferralGoogleOther Website

Please specify name of "Newspaper", "Employee Referral" or "Other Website" if selected

Emergency Contact

Emergency Contact Name

Emergency Contact Home Telephone No.

Emergency Contact Current Address

Emergency Contact Work (or message) Telephone

Conditions of Employment

Golden View Health Care Center sets high standards for its associates. We require compliance with the standards as a condition of employment. You need to carefully consider what will be required before accepting a position with us. As an employee, you would be expected to comply in full. You need to know and understand what Golden View will require of you if you are hired. Customer Service: • Totally believe in and support our customer first approach to business. • Be friendly to our customers. • Do everything you can make our customers feel welcome in our facility, including: smiling, greeting the customer promptly, being helpful, using the customer's name, saying "thank you" • Demonstrate our Values: Respect, Responsibility, Honesty, Fairness and Compassion Job Expectations: • Work hours as scheduled -- report to work on time. • Take direction from supervisors and execute directions to the best of your ability. • Maintain a positive, enthusiastic attitude at all times, and be a cooperative member of the Golden View team. • Perform job as described in Job Description Personal Appearance: • Follow dress code for your position. • Wear your Golden View name badge at all times.

YesNo

LANGUAGE TO COVER MANDATES OF NURSING FACILITY REGULATIONS AS IT PERTAINS TO PATIENT ABUSE AND HEALTH FACILITY LICENSING

Question 1. Have you ever been convicted and/or found guilty by a court of competent jurisdiction or a state agency of abuse, neglect, fraud, assault or exploitation of any person in this state or any other state? If so, please describe the offense, the date and place of convicting and the underlying circumstances or other information to help us evaluate your current fitness for employment.

YesNo

Explain Question 1. Enter N/A if you answered "NO"

Question 2. Have you ever been convicted of: (1) a felony or misdemeanor that has not been nullified; (2) sexual assault, other violent crime, assault, fraud, abuse, neglect, or exploitation of any person in this state or any other state; (3) assault of a victim sixty years of age or older? If "YES", please describe the offense, the date and the underlying circumstances or other information to help us evaluate your current fitness for employment.

YesNo

Explain Question 2. Enter N/A if you answered "NO"

Question 3. Have you ever been subject to disciplinary action by a health care licensing agency in this or any other state, or in any other United States or foreign jurisdiction? If "YES", please identify the nature and date of the action, the licensing agency involved, and the underlying circumstances or other information to help us evaluate your current fitness for employment.

YesNo

Explain Question 3. Enter N/A if you answered "NO"

I hereby certify that I have not been convicted and/or been found guilty of assault, fraud, abuse, neglect, or exploitation of any person in this state or any other states, 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 Golden View Health Care Center 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 or perpetration of an act that would result in a listing in the abuse registry may act as an automatic withdrawal of such offer of employment by Golden View Health Care Center. I further understand that any offer of employment by Golden View Health Care Center is conditional upon verification of state licensure as applicable.

YesNo

I understand and agree that any offer of employment will be contingent upon successful completion of a post job offer physical examination, medical clearance and a negative drug screen establishing that I am capable of performing the essential functions of the job for which I have applied, with or without reasonable accommodation. I certify that the statements I have made in this application are true, and I hereby grant Metro Health Foundation of NH Inc. d/b/a Golden View Health Care Center permission to verify the accuracy and completeness of this information, contact all or any of my previous or current employers and references and to investigate all educational and criminal records. I understand and agree that if my application is accepted, my employment may be terminated by me or Golden View Health Care Center at any time, with or without cause. I further understand that, if accepted, my employment is for no definite period and may be terminated without notice. I understand that any representation made by Golden View Health Care Center in connection with my application for employment must be made by an authorized officer of Golden View Health Care Center and in writing.EMPLOYEE RELEASE

YesNo

The Golden View Community is committed to hiring those individuals whose personal values will align with our organizational culture. At Golden View, we believe that every employee must possess five key values: RESPONSIBILITY, RESPECT, FAIRNESS, COMPASSION, & HONESTY.

In less than 100 words, please tell us why you would like to be an employee at Golden View

In less than 100 words, please tell us how your personal values align with those of Golden View (Be prepared to share examples)

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