APPLICATION FOR EMPLOYMENT - Masonic Village at Burlington · Masonic Village at Burlington Acacia...
Transcript of APPLICATION FOR EMPLOYMENT - Masonic Village at Burlington · Masonic Village at Burlington Acacia...
Masonic Village at Burlington Acacia Hospice Services
APPLICATION FOR EMPLOYMENT
The Masonic Charity Foundation is an equal opportunity employer and does not unlawfully discriminate in employment. No question on this
application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state,
or federal law. Equal access to employment, services, and programs are available to all persons. Those applicants requiring reasonable
accommodation to the application and/or interview process should notify the Human Resources Department.
PLEASE PRINT
Date __________________ Email ____ _______________
Name
Last First Middle
Address
Street City State Zip
Primary Phone _______ Alternate Phone _______________________
Are you a student? Yes No If employed and you are under 18, can you furnish a work permit? Yes No
Are you a United States citizen or otherwise authorized to work in the U.S. on an unrestricted basis? Yes No
(Verification will be required)
Position(s) applying for Full Time Part Time No preference
Shift desired: Date Available to Begin Work Salary Desired
I am NOT available to work the following days and/or times:
Are you currently employed? Yes No If yes, may we inquire to your present employer? Yes No
Have you ever been employed by the Masonic Charity Foundation, Masonic Village at Burlington (formerly Masonic Home of NJ) or
Acacia Hospice Services? Yes No
If yes, when? Name of Supervisor
Reason for leaving
Do you have any relatives working at the Masonic Village at Burlington? _______ Name ___________________________________________
How did you learn of this job opportunity? __________________________________________________________________________________
Did a current employee of the Masonic Village at Burlington refer you? ______________
First and last name of employee: _____________________________________________________________________________________
902 JACKSONVILLE ROAD ●BURLINGTON, NEW JERSEY 08016-3896 ●609-239-3900 ●FAX 609-239-3905
EMPLOYMENT
Beginning with your PRESENT OR MOST RECENT employment, list ALL positions held. Clearly describe the work (duties) you
personally performed. You must fill out this application completely even if a resume is being attached.
Present or Most Recent Employer Job Title Salary or Wage
Address
Dates Employed
From:
To: City/State/Zip
Telephone Number
Name of Supervisor Reason for Leaving
Job Duties:
Employer Job Title Salary or Wage
Address
Dates Employed
From:
To: City/State/Zip
Telephone Number
Name of Supervisor Reason for Leaving
Job Duties:
Employer Job Title Salary or Wage
Address
Dates Employed
From:
To: City/State/Zip
Telephone Number
Name of Supervisor Reason for Leaving
Job Duties:
Employer Job Title Salary or Wage
Address
Dates Employed
From:
To: City/State/Zip
Telephone Number
Name of Supervisor Reason for Leaving
Job Duties:
EDUCATION
School Name & Address Course of Study Grade
Completed
Degree
COLLEGE
HIGH SCHOOL
LPN’s and RN’s please provide name of school when you received your degree, if not listed above:
Describe specialized training, skills and/or list health care, business or industrial equipment operated:
License(s) and/or Certification(s) held:
Type: ___________________ Number: ____________________________________ Expiration: ________________________ State: __________________
Type: ___________________ Number: ____________________________________ Expiration: ________________________ State: __________________
Type: ___________________ Number: ____________________________________ Expiration: ________________________ State: __________________
Have you been a CNA in another state? Yes No If Yes, what state? ____________________________
REFERENCES
Please give the names and phone numbers of three (3) references. DO NOT LIST RELATIVES.
Name Telephone Years Known
Name Telephone Years Known
Name Telephone Years Known
APPLICANT’S STATEMENT
I understand that the Masonic Charity Foundation follows an employment-at-will policy, in that the employer or I
may terminate any employment any time, or for any reason consistent with applicable state or federal law. I understand that
this application is not a contract of employment. I understand that to be employed, I must be lawfully authorized to work in
the United States and I must show the employer documents that will provide this if I am offered the job.
I understand that the Masonic Charity Foundation will thoroughly investigate my work and personal history and
verify all data given on the application, on related papers, and in any interview. I authorize all individuals, schools and firms
named within to provide any information requested about me and I release them from all liability for damages in providing
this information.
I understand that I am required to abide by all policies, rules and regulations of the Masonic Charity Foundation and
agree to take a post-offer physical examination including a Mantoux (TB) test or chest x-ray, as required, and a drug test.
I understand that consideration of my employment with the Masonic Charity Foundation is contingent upon
completion of an authorized criminal background check which will be conducted following an initial interview, should one be
conducted. While a conviction(s) will not necessarily disqualify an applicant from employment, the Masonic Charity
Foundation may refuse to consider for employment any applicant who refuses to consent to a criminal background check.
Convictions that have been expunged or pardoned will not be considered by the Masonic Charity Foundation.
I certify that all statements herein are true and understand that any falsification or willful omission shall be sufficient
cause for dismal or refusal of employment.
Applicant’s Signature Date
EMPLOYER USE ONLY
TO BE COMPLETED BY DEPARMENT HEAD:
Position Dept. Budget Code
Hourly Rate Hours per pay period Access Level
Shift/Hours Status: FT FTB PT VARIABLE OC Weekend Program
New Position No Yes Req # Replacing
Additional Hiring Requirements: ______________________________________________________________________
Department Head/Hiring Director Signature Date
HUMAN RESOURCE USE ONLY
Approved to Hire: __________________________________ Date: ______________________
Human Resources Director
Date of Job Offer Start Date PIN #
Drug Test Physical Back Test
1st Mantoux 2nd Mantoux X-Ray (if applicable)
Rubella Titer _________________ Rubeola Titer _______________
Other _________________________________________________________________
Comments:
HR Recruiter Notes: ________________________________________________________________________________
__________________________________________________________________________________________________
REV. 2/2015
PRE-INTERVIEW QUESTIONNAIRE
Resumes and applications provide us with useful information but we find that is also helpful to provide candidates
with an opportunity to provide additional information. Please help us understand you better by answering these
questions. It’s important that you answer the questions honestly, so that we can accurately assess your “fit” with
this job and the organization.
NAME: DATE:
POSITION APPLYING FOR:
1. WHAT IS THE PRIMARY REASON YOU ARE APPLYING FOR THIS POSITION?
2. WHAT ARE THE TWO MOST IMPORTANT THINGS IN YOUR OPINION THAT THE MASONIC HOME DOES?
3. WHAT CHARACTERISTIC(S) DO YOU POSSESS THAT MAKES YOU GOOD AT THE POSITION YOU ARE APPLYING FOR?
4. WHAT WOULD YOU CONSIDER YOUR MOST IMPORTANT RESPONSIBILITY IN YOUR POSITION?
5. WHAT MAKES FOR A GOOD WORK EXPERIENCE?
6. HAVE YOU EVER HELD A JOB IN A SIMILAR POSITION IN ANOTHER COMPANY?
7. IF YES, SPECIFICALLY WHY DID YOU LEAVE?
8. IF YOU SHOULD BE SELECTED FOR AN INTERVIEW, YOU CAN HELP FACILITATE THE SCHEDULING BY PROVIDING US WITH THE BEST DAYS AND TIMES THAT YOU MIGHT BE AVAILABLE FOR AN INTERVIEW:
9. IF HIRED, WHAT IS YOUR AVAILABILITY? WHEN COULDYOU BEGIN WORK?
_______________________________________________________________________________________________________
Notice and Acknowledgement of Conditions of Employment
I, ___________________________, understand that as part of the pre-employment process, the
Masonic Charity Foundation of New Jersey may conduct a background investigation to
determine my suitability for the position for which I have applied.
I understand; as part of this process, I may undergo certain pre-employment medical
examinations and vaccinations and annual Mantoux testing. I understand that I may be
required to submit to a chest x-ray as the result of a positive Mantoux test. The test and X-ray
are done at a medical facility at no cost to me, or by a physician of my choice at my expense.
I understand; I will be required to submit to a drug screening through urinalysis; a negative
result on the drug screening is a condition of employment. I will be eliminated from employment
consideration if the results are positive.
I understand; I can refuse to undergo the drug testing. However, if I refuse or fail to provide a
urine sample for testing, I will be rejected for employment.
I understand; if I produce a positive test result for illegal drug use; those results will be held on
file and I will be precluded from applying for future employment for a period of at least one year.
I understand; if I produce a positive test result and I am a licensed medical professional or hold
a Commercial Driver’s License (CDL); the authority issuing said license may be made aware of
those results.
I understand; I will also be subject to whatever future testing is required by law for the position
I hold.
I further understand; I will be subject to random drug testing; refusal or failure to submit to
such testing will be grounds for dismissal. I also understand; a negative result for such testing
is a condition of continued employment; a positive test result may be grounds for dismissal.
I understand; any testing required as part of a reinstatement program will be at my expense.
A positive test at any time will result in immediate dismissal with no future opportunity for
reinstatement.
By my signature I acknowledge; I have read, understand and agree to comply with the
conditions of employment as stated above.
_________________________________________ _______________________________________
Applicant Signature/Date Signature of Parent/Guardian if a minor
902 JACKSONVILLE ROAD BURLINGTON, NEW JERSEY 08016-3896
609-239-3900 FAX 609-239-3905
Availability Questions
Do you have a vacation planned over the next 6 months?
YES NO
If yes, please provide dates: _____________________
Is there a day of the week that you cannot work?
Monday Tuesday Wednesday Thursday
Friday Saturday Sunday
(Only circle days you cannot work)
Is there a shift you cannot work?
1st (7a-3p) 2nd (3p-11p) 3rd (11p-7a)
(Only circle days you cannot work)
Masonic Charity policy:
All nursing team members must work every other weekend.
Do you have a weekend preference: ________________________________
By signing below I certify that the above information is true and
accurate to the best of my knowledge. I understand this document is
solely for discussion purposes and does not in any way guarantee time
off.
__________________________________________ ______________________________
Signature Date
REQUEST FOR REFERENCE
APPLICANT’S STATEMENT
I hereby grant permission to the Masonic Charity Foundation to verify the information I have provided on
the employment application; they may contact my previous and/or present employer for information
relative to my employment with them.
I hereby release from all liability and damages those individuals or companies who provide such
information.
_________________________________________ ________________________
Applicant’s Signature Date (Do not write below this line)
To: _____________________________________________
_____________________________________________
Re: _____________________________________________ ______________________________ Applicant’s name Social Security Number
POSITION APPLYING FOR: ____________________________________________
The Masonic Charity Foundation provides residential, skilled nursing and hospice services. The
applicant has applied for the position listed above. Your confidential verification of the
information below will be helpful in our consideration of this applicant. We would greatly
appreciate an early reply.
Thank you,
Human Resources Department
609-239-3805
EMPLOYER RESPONSE
Dates of employment: ___________________ to _____________________ Yes No
Position held: _______________________________ Yes No
Reason for leaving ________________________________________ Yes No
Is applicant eligible for rehire? Yes No If no, why not? _______________________________
_____________________________________________________________________________________________________
COMMENTS: _______________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________ _______________________________________________
Signature and Title Printed Name
______________________________________________ ___________________________
Phone number Date
902 JACKSONVILLE ROAD BURLINGTON, NEW JERSEY 08016-3896
609-239-3900 FAX 609-239-3905
EMPLOYMENT/SERVICE VERIFICATION FORM Human Resources
Telephone: 609-239-3898
Fax: 609-239-3905
Pursuant to the Health Care Professional Responsibility and Reporting enhancement Act (HCPRREA),
(P.L. 2005, c.83, effective October 30, 2005) which enables health-care entities (a) to exchange certain
information regarding health-care professionals (b) and in the interest of verifying such information, this
form seeks information regarding the health-care professional named below. Upon inquiry from a
health-care entity about a current or formerly employed health-care professional, health care entities
must provide the following information about that health-care professional (see N.J.S.A. §§ 26:2H-12.2c):
(1) job performance as it relates to patient care based upon job-performance evaluations;
(2) eligibility for re-employment at the health-care entity; (3) reason for separation for a formerly
employed health-care professional, and (4) copies of any notifications and supporting documentation sent
to the New Jersey Division of Consumer Affairs (DCA), medical practitioner review panel, and a
professional or occupational licensing board of the DCA within seven years preceding the date of this
inquiry (see N.J.S.A. §§ 26:2H-12.2a and 12.2b).
TO BE COMPLETED BY CANDIDATE (Please print)
Name of Candidate: ____________________________________________________________________________
Maiden Name/Other Names Used: _____________________________________________________________
Professional License or Certification Number: _________________________________________________
Position Applied For: ___________________________________________________________________________
Employer (Name & Address): ___________________________________________________________________
_____________________________________________________________ Phone: __________________________
Title(s) of Position(s) Held: _____________________________________________________________________
Dates Employed From: ____________________________________ To: _____________________________
Candidate Signature: _______________________________________ Date: ___________________________
TO BE COMPLETED BY FORMER/CURRENT HEALTH-CARE ENTITY/EMPLOYER
SECTION I
Name When Employed: __________________________________________________________________________
Title(s) of Position(s) Held: ______________________________________________________________________
Dates Employed From: ____________________________________ To: _____________________________
(a) The HCPRREA defines “health-care professionals” as health-care facilities licensed pursuant to N.J.S.A. §§ 26.2H-1 state and
county psychiatric hospitals and development centers, HMO’s, carriers offering managed-care plans, staffing registries and
home-care service agencies.
___________________________________________________________________________________________________________________________
902 JACKSONVILLE ROAD BURLINGTON, NEW JERSEY 08016-3896 609-239-3900 FAX 609-239-3905
(b) The HCPRREA defines “health-care professionals” as individuals licensed or authorized to practice a health-care profession
regulated by DCA or other professional and occupational licensing boards including but not limited to, physicians; podiatrists;
nurses; pharmacists; physical, occupational and respiratory therapists; psychologists, psychoanalysts; social workers; audiologists,
and speech-language pathologists; optometrist; ophthalmic dispensers and technicians; dentists; orthodontists and prosthetists;
marriage and family therapists; veterinarians, and chiropractors; and acupuncturists. Health-care professionals also include
home-health aides certified by the board of nursing and nurse aides and personal-care assistants certified by the Department of
Health and Senior Services.
REASON FOR SEPARATION OF EMPLOYMENT (please check all that apply)
Voluntary Reasons Involuntary Reasons
Voluntary Resignation Involuntary Lay-off
Voluntary Relocation Involuntary Discharge for Performance
Voluntary Lay-off Involuntary Discharge for Misconduct
Voluntary Resignation in Lieu of Discharge Voluntary Discharge for Attendance
Abandoned Position Other (provide description) _________________
Other (provide description) _________________
SECTION II
For all health-care professionals, please describe the health-care professional’s job performance as it
relates to patient care. Job performance relates to the suitability of the health-care professional for
re-employment at the health-care entity, the professional’s skills and abilities as they relate to suitability
for future employment at a health-care entity. Any job performance information provided should be
based on the professionals’ job-performance evaluation considering those evaluations signed by the
evaluator and shared with the health-care professional and the professional’s response to that evaluation
(see N.J.S.A. 26:2H-12.2c). Please check the appropriate box below regarding the health-care
professionals skills and abilities relating to patient care. (Attach additional pages as needed)
Please indicate date of the last/most recent performance evaluation: ________________________
Meets Standards Does not meet Standards
SECTION III
Is the health-care professional eligible for re-employment by the health-care entity? Yes or No
If “No, please provide an explanation as it relates to patient care (see Section II above)
SECTION IV
During the seven years preceding the date of this inquiry (see above), have you submitted any
notification to the New Jersey DCA, medical practitioner review panel, or occupational licensing board
about this health-care professional? Yes or No
If yes, please provide a copy of the notification and all supporting documentation as required by
N.J.S.A. 26:2H-12.2c
FORM COMPLETED BY:
___________________________________________ ___________________________________________
Print Name Signature
___________________________________________ _________________________
Title Date
___________________________________________ Phone Number