• Employment Application for Beadles Activities Staff

  • This employer does not discriminate in its hiring decisions or in any other employment decision on the basis of race, color, sex, religion, citizenship, national origin, veteran status, age or upon a physical or mental disability which is unrelated to the applicant's/employee's ability to perform the essential functions of the position.

  • Date of Application:*
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  • Date Available to Start Work:*
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Employment Desired:

  • Hours available to work:*
  • Will you accept employment of:*

  • U.S. Military Record

  • Date Entered:
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  • Date of Discharge:
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  • Prior Work History

    List your last four (4) jobs beginning with your most recent or current employer.
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  • Dates Employed From:
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  • May we contact your present employer?*
  • Have you ever been terminated or asked to resign from any position?*

  • 4 Educational Background

    List all educational schools attended with degrees, diplomas or certificates received.
  • Dates Attended From:*
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  • Dates Attended To:*
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  • Dates Attended From:
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  • Dates Attended To:
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  • Dates Attended From:
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  • Dates Attended To:
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  • Certification

    If you hold a current certification as an Activity Assistant, Director, or Consultant (NCCAP certification), or have successfully completed the designated course for Activities and Social Services Director
  • If you hold a current certification, select it below:

  • References

    List name, address and telephone number of three references who are not relatives or former employers.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • 6 Background Information

  • If you answer YES to any of the questions below, explain in the space after the question. The explanation for a YES answer should include, but not be limited to:

    1. State and/or jurisdiction
    2. Nature of complaint
    3. Disposition of complaint; e.g., "dismissed insufficient evidence"
    4. Date of disposition
    5. Copies of any correspondence received by applicant with regard to the complaint 
  • Have you ever been arrested, charged with, entered a plea of guilty, no contest, convicted of or been sentenced for any criminal offense in any state or US jurisdiction?*
  • Have you ever been found to have violated any state, US jurisdiction or federal law regulating the practice of a health care profession?*
  • Have you had any certificate, license, registration or other privilege to practice a health care profession denied, revoked, suspended, restricted, reprimanded, censured or placed on probation by a state or US jurisdiction, federal or foreign authority or have you ever surrendered such credential to avoid or in connection with action by such authority?*

  • Applicant's Certification and Agreement

    PLEASE READ CAREFULLY - If you answer NO to any of the questions below, explain in the space after the question
  • I understand that the employer has the right to proceed with any criminal background check*
  • I understand that as a part of the job selection process, I may be required to take a drug screening test at the time of employment and if requested in accordance with the state and federal law at anytime during my employment. A test result that has been confirmed as positive will eliminate me from employment. If I refuse to sign this form and submit to drug testing the employer will reject my application.*
  • I understand that I am required to have a physical examination and I hereby consent to take a physical examination and any future physical examinations as required by the employer.*
  • I understand that if I am hired I will be required to produce proof that I have a legal right to work in the U.S.A. in accordance with the IRCA of 1986.*
  • I understand that this form is not an employment contract*

  • I certify that the information provided on this application is true and complete and I understand that false information or omission of facts may disqualify me from employment and may cause termination if discovered at a later date.

  • Date of Signature*
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  • Personal Information for Background Check

  • Date of Birth:*
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  • Sex:*
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  • Criminal Arrest Check List

  • Employment at this employer shall not be considered if the below signed individual has been convicted of one of the following crimes as stated by Oklahoma Statute, Section 1-1950.1 (F) (1) Title 63 (A through P of the list in this section):

    1. Assault, battery or assault and battery with a dangerous weapon,
    2. Aggravated assault and battery,
    3. Murder or attempted murder,
    4. Manslaughter except involuntary manslaughter,
    5. Rape, incest or sodomy,
    6. Indecent exposure and Indecent exhibition,
    7. Pandering,
    8. Child abuse,
    9. Abuse, neglect or financial exploitation of any person entrusted to his care or possession,
    10. Burglary in the first or second degree,
    11. Robbery in the first or second degree,
    12. Robbery or attempted robbery with a dangerous weapon, or imitation firearm,
    13. Arson in the first or second degree,
    14. Unlawful possession or distribution, or intent to distribute unlawfully, Schedule I through V drugs as defined by the Uniform Controlled Dangerous Substance Act,
    15. Grand larceny, or
    16. Petit larceny or shoplifting within the past seven (7) years.

    It is further understood that if I am hired, it will be as a temporary employee until my criminal background check is received by the employer.

    If I have no criminal record in accordance with state law, I may be considered for employment, subject to training requirements and other requirements of the job for which I am applying with this employer.

    I hereby certify that I have no previous convictions as listed in the Oklahoma Statute, Section 1-1950.1 (F) (1) Title 63 (A through P of the list in this section). I hereby give the Oklahoma State Department of Health and the Oklahoma State Bureau of Investigations authority to proceed with criminal record history checks as required by law.

  • Date of Signature*
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  • Should be Empty: