Employment Application

Bethel Lutheran Nursing & Rehabilitation Center and Arbor House Assisted Living are an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Applicants requiring reasonable accommodation in the application and/or interview process should notify a representative of the organization.

Job Applying for

Job

General Information

First Name*

Middle Initial

Last Name*

Address 1*

Address 2

City*

State*

Zip*

Phone*

Date Available*

Shift*

Position*

Hours/Days/Shifts You are UNABLE to Work*

How were you referred to Bethel Lutheran Nursing & Rehabilitation Center?*

Personal Data

At least 16* Yes No

Have you ever applied to/worked for Bethel Lutheran Nursing & Rehabilitation Center before?* Yes No

If yes, please explain (include dates):

Have you ever been convicted of, or pled guilty or no contest to, a crime other than a minor traffic violation?* Yes No

If yes, please explain (include the date of final disposition of the case and the nature of the offense):

This information will not necessarily disqualify you from employment but false or misleading information will. Factors such as age and time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account.

Professional Licenses, Certificates, and Permits

List All Professional License, Certificates or Permits:

Name	State	Number	Expiration Date

Have you ever had a professional license disciplinary action, or has your license ever been revoked, suspended, restricted or modified in any state?* Yes No

If yes, please attach full details.

If you do not have a required registration or license, have you applied for one? Yes No

If an examination is required, what date are you scheduled to take the examination?

If not licensed in North Dakota, have you applied for reciprocity? Yes No