Bethesda Employment Application

15487 State Highway 86 Meadville, PA 16335

814-724-7510 phone

814-724-8686 fax

human.resources@bethesda1919.org
EMPLOYMENT APPLICATION
It is the policy of Bethesda Lutheran Services to provide equal opportunity in employment with no regard for race, color, religion, citizenship, disability, national origin, sex, age, genetic information or any other protected status under applicable federal, state or local law. Due to regulatory standards some positions require applicants to be 21 years of age.
APPLICANT INFORMATION:
Last Name
First
Middle
Today's Date

MonthDayYear
Date
Street Address
Cell Phone
City. State, Zip Code
Position applying for
Are you available for: Full Time Part Time
Desired compensation
Are you willing to work overtime? Yes or No

Are you legally authorized to work in the United States? Yes or No
Yes or No
How did you learn about Bethesda?
When are you available to begin work?
EDUCATION:
Highschool: Name of School & Degree Obtained
College: Name of School, Course of Study & Degree Obtained
Other College or School Attended
MILITARY SERVICE:
Branch of Service
From
Describe any special training you received
Date of Discharge

MonthDayYear
Date
Are you licensed or have any certifications which may assist in the job? Please explain

Registration or License Number: Registration or License Number:
Registration or License Number
State Issued
Expiration Date

MonthDayYear
Date
Registration or License Number
State Issued
Expiration Date: Expiration Date:
Expiration Date

MonthDayYear
Date
Company Name
EMPLOYMENT HISTORY: Start with your current or most recent employer. Phone Number: Company Name:
Address
Dates of Employment

MonthDayYear
Date
Supervisor's Name
Final Pay Rate
Job Title & Description of Duties
Reason for Leaving
Company Name
Address
Dates of Employment: From
Job Title & Description of Duties
Reason for Leaving
Company Name
Address
Dates of Employment: From

MonthDayYear
Date
To
Final Pay Rate
Job Title & Description of Duties
Reason for Leaving
Company Name
Address
Dates of Employment: From
From
To
Supervisor's Name
Final Pay Rate
Job Title & Description of Duties
Reason for Leaving
We may contact present or former employers unless you indicate those you do not want us to contact.
Employer Name
Reason
List Two Professional References
1. Name
Nature of Relationship
Phone Number
Address
2. Name
Nature of Relationship
Phone Number
Address
List One Personal Reference - No Relatives Please
1. Name
Nature of Relationship
Phone Number
Address
Have you ever been employed at Bethesda Lutheran Services before? YesNo If yes, please state dates of employment. position, reason for leaving and under what name you were employed:
State the names of relatives and friends working at Bethesda to your knowledge
Please read carefully before signing this form.

Bethesda Lutheran Services adheres to the requirements under Regulatory Standards, the Child Protective Services Law, and agency policy regarding background check information. The majority of positions within our agency are subject to a variety of clearance checks including but not limited to FBI, Child Abuse, PA Criminal Check, and Driver History. If you are offered a position with Bethesda Lutheran Services, the offer of employment will be contingent upon satisfactorily completing these clearances within the accepted guidelines under Regulatory Standards, the Child Protective Services Law, and agency policy.

I understand that upon receiving an offer of employment, a physical examination and drug screening may be required.

Iunderstand this application remains current for six months. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

By signing below, I am indicating that all the information provided by me in this application for employment is true and accurate to the best of my knowledge. I understand that if employed, any misrepresentation or omission of fact on this application shall be considered cause for dismissal.
Signature of Applicant

Clear
Date

MonthDayYear
Date
Thank you for your interest in employment at Bethesda Lutheran Services!

Accredited/Certified by The Joint Commission
Should be Empty:

EMPLOYMENT APPLICATION

APPLICANT INFORMATION:

EDUCATION:

MILITARY SERVICE: