Name and AddressFull Name* Phone* Email* Street* City* State* Zip* Additional InformationHave you ever been known by a different name?YesNoIf yes, what was it?Please explainHave you ever been employed by Golden View?YesNoIf "YES", department? Enter N/A if not applicableDates of EmploymentWhy did you leave?:List any friends or relatives working for usName 1Relationship 1Name 2Relationship 2PositionWhat position are you applying for?Salary ExpectationsWhat are the two (2) most important factors to you in this position?Important Factor #1 in this positionImportant Factor #2 in this positionWork ScheduleWhat type of employment do you want? (check one)Full-timePart-timeWhen 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)?YesNoWhat days & times are you available to work? Include a.m. or p.m.Employment StatusAre you currently employed?YesNoIf 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)YesNoIf yes, what impact does this have on your availability for work?Employment HistoryHave you ever worked in a health care center before?YesNoIf 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 RecordList 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 employerCompany* Company Address* Company Phone* Dates Employed* Last Salary* Last Position Held* May we contact your present employer?YesNoLast Supervisor's Name* Supervisor Contact Information* Why did you leave?Be specificLike MOST about the job?Be specificLike LEAST about the job?Be specificEmployer 2Company 2Company 2 AddressCompany 2 TelephoneDates Employed at Company 2Last Salary at Company 2Last Position at Company 2May we contact company 2?YesNoLast supervisor's name at company 2Supervisor contact info at company 2Why did you leave company 2Be specificLike MOST about the job (2)?Be specificLike LEAST about the job (2)Be specificEmployer 3Company 3Company 3 AddressCompany 3 PhoneDates employed at Company 3Last Salary at Company 3Last Position at Company 3May we contact your previous employer (3)?YesNoLast supervisor's name at company 3Supervisor's contact info at Company 3Why did you leave company 3?Be specificLike MOST about the job (3)Be specificLike LEAST about the job (3)?Be specificEducationName of High SchoolIf you attended high schoolHigh School CityLast year completed at high school:Graduated high school?YesNoName of college attendedIf you attended collegeLast year completed in collegeGraduated from college?YesNoMajor course of studyDegreeIf applicableTraining & LicensesDo you have any other kind of education/training?YesNoIf yes, please describeDo you have any professional licenses?YesNoIf yes, what type and expiration dateDo you have a dementia training certificate?YesNoAre you legally authorized to work in the United States?YesNoDocument NumberIf applicableIf hired, verification will be required consistent with Federal Law.ReferencesGive the names of 2 persons who are not relatives or former employers, who have known you for five (5) years or more.Reference 1 RelationshipReference 1 NameReference 1 Current AddressReference 1 City/State/ZipReference 1 Telephone No.Reference 1 Number of Years KnownReference 2 RelationshipReference 2 NameReference 2 Current AddressReference 2 City/State/ZipReference 2 Telephone NoReference 2 Number of Years KnownReferral InformationHow were you were referred to Golden View?NewspaperEmployee ReferralGoogleOther WebsitePlease specify name of "Newspaper", "Employee Referral" or "Other Website" if selectedEmergency ContactEmergency Contact NameEmergency Contact Home Telephone No.Emergency Contact Current AddressEmergency Contact Work (or message) TelephoneConditions of EmploymentGolden 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.YesNoLANGUAGE TO COVER MANDATES OF NURSING FACILITY REGULATIONS AS IT PERTAINS TO PATIENT ABUSE AND HEALTH FACILITY LICENSINGQuestion 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.YesNoExplain 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.YesNoExplain 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.YesNoExplain 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.YesNoI 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 RELEASEYesNoThe 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 ViewIn less than 100 words, please tell us how your personal values align with those of Golden View (Be prepared to share examples) Submit Form