Employment Application

Fairview Haven is committed to the highest level of quality and sets a high standard for our team members. Please read the below statements to ensure that your values align with the values and principles of Fairview Haven.

Mission Statement:

An Apostolic Christian Community where choice is valued, growth is encouraged, and life abounds.

Vision Statement:

Putting the Gold Back into the Golden Years.

How we apply these statements:

As a team member at Fairview Haven, you will respect the Holy Scriptures and God's Spirit among us and will try to uphold them and support their presence in the daily lives of the seniors we serve. You recognize you have a blessed privilege to serve these loved ones in their home.
As a team member at Fairview Haven, you will strive with the help of God to provide the highest quality of life to all we serve without regard to race, color, religion, or ability to pay.
As a team member of Fairview Haven, you will be committed to creating a home supporting the spiritual, physical, mental, and emotional needs of those we serve.
As a team member of Fairview Haven, you will honor the dignity of all residents and their right to make choices for themselves in a safe and nurturing environment.
As a team member of Fairview Haven, you will seek to enhance and embrace life, as well as provide support and care when the time of life's departure nears.
As a team member of Fairview Haven, you will strive to be a good steward of our residents' resources and seek to engage families and community in our mission of caring.
As a team member of Fairview Haven, you will value other team members and assist in creating an environment in which everyone can flourish and share in loving care.

I understand the above statements and my values align with the principles and values of Fairview Haven.

Signature

By typing your name above, you are adding your signature.

Date

First Name

Middle

Last Name

Street Address

City

State

Zip Code

Phone Number

Format: (000) 000-0000.

Secondary Phone Number

Format: (000) 000-0000.

Email

SSN

Are you entitled to work in the United States?

Individuals with disqualifying convictions, as listed in the Healthcare Worker Background Check Act, are prohibited from working in any position at Fairview Haven. Please review the following list:

Disqualifying Offense List

Have you ever been convicted of a disqualifying offense as listed on the Disqualifying Offense List?

If yes, please explain:

What position(s) are you applying for? (select all that apply)

Choose Any

Expected Hourly Rate

Date Available

Professional License Certification (RN, LPN, CNA, Etc.)

Date Received

State

License Number

Has your professional license ever been suspended, revoked, or on probation for any reason?

Name of who or how you were referred you to Fairview Haven

If a current Fairview Haven employee referred you, please list their name so they can get a referral bonus!

Have you ever worked at Fairview Haven?

If yes, when?

Do you know anyone who lives or works at Fairview Haven? Who?

What are your long range occupational goals?

High School - Name

Last grade completed

College/University - Name

Last year completed

Major or Emphasis

Other applicable education, special skills, training or proficiencies

**CNAs are required to provide employment history from the time of certification to the present**

Employer #1 (Current or Most Recent)

Employer #1 City, State

Employer #1 Phone Number

Position - Employer #1

Dates of Employment - Employer #1

Reason for Leaving - Employer #1

Name of Immediate Supervisor - Employer #1

May we contact? - Employer #1

Employer #2

Employer #2 City, State

Employer #2 Phone Number

Position - Employer #2

Dates of Employment - Employer #2

Reason for Leaving - Employer #2

Name of Immediate Supervisor - Employer #2

May we contact? - Employer #2

Employer #3

Employer #3 City, State

Employer #3 Phone Number

Position - Employer #3

Dates of Employment - Employer #3

Reason for Leaving - Employer #3

Name of Immediate Supervisor - Employer #3

May we contact? - Employer #3

To provide additional employment history, please upload your resume below.

**MUST provide 3 references who are NOT related to you**

Reference #1 Name

Reference #1 Phone Number

Reference #2 Name

Reference #2 Phone Number

Reference #3 Name

Reference #3 Phone Number

By signing this application, I certify and affirm the following:

that the information provided on this application is true and complete. I understand any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date.
that employment will be conditioned upon successfully passing a pre-employment physical examination, fitness for duty examination, pre-employment drug screening, and criminal history check.
that I am authorizing persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information.
that my employment is at-will which means I may terminate the employment relationship at any time and for any reason with or without notice and that Fairview Haven has that same right. I understand no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized.

Signature

By typing your name above, you are adding your signature.

Date

Employment Application

Personal Information

Education

Prior Work Experience

Personal References

Certification and Signature