Bonnie Brae Employment Application

APPLICATION FOR EMPLOYMENT
Equal access to programs, services and employment opportunities is available to all persons without regard to rate, creed, religion, color, national origin, ancestry. age, marital status, civil union status, domestic partnership status, affectional or sexual orientation, sex (including pregnancy gender identity or expression, disability, liability for military service, atypical heredity cellular or blood trait, genetic information, breastfeeding. status as a registrant for medical cannabis, or any other basis protected by federal, state, and/or local law. In accordance with the Americans with Disabilities Act and/or applicable state and local Laws. applicants requiring reasonable accommodations for the application and/or interview process should notify the Human Resources Department Examples of reasonable accommedations include making a change to the application process; providing written materials in an atternate format such as braille, large print, or audio recording; using a sign language interpreter; using specialized equipment; or modifying testing conditions.
Name

Last NameFirst NameMiddle Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone
Format: (000) 000-0000.
Cellular/Other Phone
Format: (000) 000-0000.
Email Address
example@example.com
Position(s) applied for
Date of application

MonthDayYear
Date
Referral Source (e.g., Employee Referral, Indeed, Company's Website, Career Fair etc.)
If necessary, best time to call you is field. Time
Best number to reach you Home Cellular/Other
May we contact you at work Yes No
If yes, work number and best time to call Area Code Phone Number Time
If you are under 18 and it is required, can you furnish a work permit?
N/A Yes No
In no, please explain Type a label
Have you ever submitted an application here before? Yes No
If yes, give date(s) and position(s) Type a label
Have you ever been employed here before?   Yes   No
If yes, give dates   Date   To   Date
Is this application a request for reemployment following an extended military leave of absence from this company?   Yes   No
If yes, additional information may be requested.
YesNo
Date available for work?

MonthDayYear
Date
What is your desired salary range or hourly rate of pay?
$ Per Type a label
Full timePart timeEducational Co-opSeasonalTemporary
YesNo
YesNo
YesNoN/A
YesNo
If no, please explain:
Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonanle accommodation)? This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existance of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage to the extent permitting by law.

YesNoNeed more information about the job's "essential functions" to respond
Driver's License number required if driving may be required in job for which you are applying Driver's license StateState Initials
YesNo
YesNo
If yes, please explain
Employment History

Employment Information starting with your most recent employer, provide the following information.
Employer 1
Telephone #
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street address

Street Address Line 2

CityState

Postal / Zip Code
Starting job title/Final job title
Dates employed from

MonthDayYear
Date
Dates employed to

MonthDayYear
Date
Immediate Supervisor’s name and title
YesNoLater
Supervisor’s Email
example@example.com
Why did you leave?
Summarize the type of work performed and job responsibilities
What did you like most about your position?
What were the things you liked least about your position
Employer 2
Telephone #
Format: (000) 000-0000.
Address

Secet address

Street Address Line 2

CityState

Postal / Zip Code
Starting job title/Final job title
Dates employed from

MonthDayYear
Date
Dates employed to

MonthDayYear
Date
Immediate Supervisor’s name and title
YesNoLater
Supervisor’s Email
example@example.com
Why did you leave?
Summarize the type of work performed and job responsibilities
What did you like most about your position?
What did you like least about your position
Employer 3
Telephone #
Format: (000) 000-0000.
Address

Street address

Street Address Line 2

CityState

Postal / Zip Code
Starting job title/final job title
Dates employed from

MonthDayYear
Date
Dates employed to

MonthDayYear
Date
Immediate Supervisor’s name and title
YesNoLater
Why did you leave
Supervisor’s Email
example@example.com
Summarize the type of work performed and job responsibilities
What did you like most about your position
What did you like least about your position
Employer 4
Telephone #
Format: (000) 000-0000.
Address

Street address

Street Address Line 2

CityState

Postal / Zip Code
Starting job title/final job title
Dates employed from

MonthDayYear
Date
Dates employed to

MonthDayYear
Date
Immediate Supervisor’s name and title
YesNoLater
Supervisor’s Email
example@example.com
Why did you leave
Summarize the type of work performed and job responsibilities
What did you like most about your position
What did you like least about your position
Employment History (continued)
Explain any gaps in your employment, other than those due to personal illness. injury. or disability.
YesNo
If yes, please explain
Skills and Qualifications
Summarize any special training, skills, languages, licenses, and/or certificates that may assist you in performing the position for which you are applying
Computer Skills Include software titles and level of experience, such as basic, intermediate, or advanced
Word Processing
Spreadsheet
Presentation
Email
Internet
Other Type Computer Skill Here
Other    Type Computer Skill Here
Other     Type Computer Skill Here
Educational Background

Starting with your most recent school attended, provide the following information.
School name, city and state
# of years completed
DiplomaGEDDegreeCertificateOther
GPA or Class Rank
Major/Minor
School name, city and state (2)
# of years completed
DiplomaGEDDegreeCertificateOther
GPA or Class Rank
Major/Minor
School name, city and state (3)
# of years completed
DiplomaGEDDegreeCertificateOther
GPA or Class Rank
Major/Minor
School name, city and state (4)
# of years completed
DiplomaGEDDegreeCertificateOther
GPA or Class Rank
Major/Minor
References
List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.
Name of reference 1
Title
School name, city and state (3)
Relationship to you
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Years known
Name of reference 2
Title
Relationship to you
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Years known
Name of reference 3
Title
Relationship to you
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Years known
Related Information

When answering these questions, please exclude any information that would reveal race, creed, religion, color, national origin, ancestry, age, marital status, civil union status, domestic partnership status, affectional or sexual orientation, sex (including pregnancy) gender identity or expression, disability, liability for military service, atypical heredity cellular or blood trait, genetic information, breastfeeding, status as a registrant for medical cannabis, or other simitarly protected status.
To what job related organizations (professional, trade, etc.) do you belong?
List special accomplishments, publications, awards, etc.
List any relevant volunteer work.
Is there any other job related information you want us to know about you?
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.
Signature of Applicant

Clear
Date

MonthDayYear
Date
This product is designed to provide accurate and authoritative information. However, it is not a substitute for legal advice and does not provide legal opinions on any specific facts or services. The information is provided with the understanding that any person or entity involved in creating, producing or distributing this product is not liable for any damages arising out of the use or inability to use this product. You urged to consult an attorney concerning your particular situation and any specific questions or concerns you may have.

Important note: This is approved for the purchaser only. This form may not be shared publicly or with third parties.
Bonnie Brae Candidate Referral Form
Issued: 4/02/01

Revised: 5/23/02
Name of Candidate
Referred by:
Department
Date

MonthDayYear
Date
Signature

Clear
For Human Resources Office Use Only
Permission Letter for Motor Vehicle Record (MVR) Report

Consumer Report may be obtained as part of Bonnie Brae's Evaluation of my job application/employment. The reports may be procured by William H. Connolly and Co. Insurance and/or Bonnie Brae, and may include my driving record, an assessment of my insurability under the Company's insurance coverages or other consumer reports. By signing this disclosure, I hereby authorize the Company to procure such reports and additional reports about me from time to time as it deems appropriate, to evaluate my insurability or for other permissible purposes. Additionally, my signature acknowledges that I have received a copy of "A Summary of Your Rights Under the Fair Credit Reporting Act."
Print Name
Signature

Clear
Date

MonthDayYear
Today's Date
Street Address as stated on your license
Street Address
City
State
Zip Code
Driver's License Number
New JerseyOther, please enter state below
Date of Birth

MonthDayYear
Date
Social Security #
Accredited by the Joint Commission
Print Name
Applicant Signature: I attest that I have not been convicted of any disqualifying crimes pursuant to the provisions listed above.

Clear
Date

MonthDayYear
Date
Accredited by the Joint Commission on Accreditation of Healthcare Organizations

Issued: 2/26/02 Revised: 3/26/04
Employment and Education Release

I hereby give my permission is release the employment and educational information requested to Bonnie Brae.

This information is to be used to determine eligibility for the employment at Bonnie Brae
Print Name
Signature

Clear
Date

MonthDayYear
Date
Accredited by the Joint Commission on Accreditation of Healthcare Organizations

Issued: 6/27/00 Revised: 7/11/03
Should be Empty:

APPLICATION FOR EMPLOYMENT

Employment History

Skills and Qualifications

School name, city and state (4)

References