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Which Location Are You Applying For?
*
Brewster Parke in Brewster, OH
Bel Air Care in Alliance, OH
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Job Application Form
Brewster Parke, Inc
Job Application Form
Bel Air Care Center
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What position are you interested in/applying for?
*
LPN/RN
Assisted Living Attendant
State Tested Nurse Aide (STNA)
Dietary
Housekeeping
Maintenance
Other
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Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What position are you interested in/applying for?
*
LPN/RN
Assisted Living Attendant
State Tested Nurse Aide (STNA)
Dietary
Housekeeping
Maintenance
Other
What type of position are you seeking?
*
Full Time
Part Time
PRN / As Needed
What shifts are you available to work?
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Afternoon Shift
Day Shift
Night Shift
Other
Are you willing to work weekends or holidays if needed?
*
Yes
No
Please list any specific days or times you are unavailable.
Have you worked for Brewster Parke or Bel Air Care Center in the past?
*
No
Yes, (Explain with detail, position held, reason for leaving.)
Do you have any relatives that work at Brewster Parke?
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No
Yes, (Please list their name in the box)
Do You Smoke Tobacco Products?
*
Yes
No
Do you have a reliable mode of transportation to get to work?
*
Yes
No
Highest Education Level Completed:
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GED / High School Equivalent
Some College / Vocational
Associate’s / Bachelor’s / Graduate Degree
Other
Please list any relevant experience or training that you have had that supports your qualifications for the position you are applying for:
Example: Forklift Operator Certified, ServSafe Certification
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Licensure & Certifications
Do you hold any professional licenses or certifications?
*
Yes
No
Type
State Tested Nurse Aide
LPN
RN
Other (Please Specify)
License/Registration #:
*
Expiration Date:
*
-
Month
-
Day
Year
Date
State Issued:
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Any restrictions on your license?
*
No
Yes (Please Explain)
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Employment History
Please include the last 10 years of employment.
Employer 1 (Most Recent)
Most Recent Employer
*
Most Recent Employer Address and Time with Employer
*
Street Address
City, State, Zip
Start Date
End Date
Duties Performed at Most Recent Employer
Most Recent Employment Details Including Contact Information of Supervisor
*
Role/Position at Employer
Duties Performed at Employer
Supervisor Email
Supervisor Phone #
Supervisor Name
Reason For Leaving
*
May we contact this employer?
*
Yes
No
Does this employer cover the past 10 years of employment?
*
Yes
No
Employer 2
Employer #2 Name (Company Name)
Employer #2 Address and Time with Employer
Street Address
City, State, Zip
Start Date
End Date
Reason For Leaving
Duties Performed at Employer #2
Employment #2 Details Including Contact Information of Supervisor
Role/Position at Employer
Duties Performed at Employer
Supervisor Email
Supervisor Phone #
Supervisor Name
Reason For Leaving
May we contact this employer?
Yes
No
Do the last 2 employers cover the past 10 years of employment?
*
Yes
No
Employer 3
Employer #3 Name (Company Name)
Employer #3 Address and Time with Employer
Street Address
City, State, Zip
Start Date
End Date
Reason For Leaving
Duties Performed at Employer #3
Employment #3 Details Including Contact Information of Supervisor
Role/Position at Employer
Duties Performed at Employer
Supervisor Email
Supervisor Phone #
Supervisor Name
Reason For Leaving
May we contact this employer?
Yes
No
Employer 4
Employer #4 Name (Company Name)
Employer #4 Address and Time with Employer
Street Address
City, State, Zip
Start Date
End Date
Reason For Leaving
Duties Performed at Employer #4
Employment #4 Details Including Contact Information of Supervisor
Role/Position at Employer
Duties Performed at Employer
Supervisor Email
Supervisor Phone #
Supervisor Name
Reason For Leaving
May we contact this employer?
Yes
No
Employer 5
Employer #5 Name (Company Name)
Employer #5 Address and Time with Employer
Street Address
City, State, Zip
Start Date
End Date
Reason For Leaving
Duties Performed at Employer #5
Employment #5 Details Including Contact Information of Supervisor
Role/Position at Employer
Duties Performed at Employer
Supervisor Email
Supervisor Phone #
Supervisor Name
Reason For Leaving
May we contact this employer?
Yes
No
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Professional References
Provide 3 supervisors, managers, or co-workers who have known you for at least six months. Do not list family members, in-laws, or anyone living in your household.
Reference #1
Name
*
First Name
Last Name
Title / Relationship
*
Contact Info for reference #1
*
Phone
Email Address
City
State / Province
Postal / Zip Code
Reference #2
Name
*
First Name
Last Name
Title / Relationship
*
Contact Info for reference #2
*
Phone
Email Address
City
State / Province
Postal / Zip Code
Reference #3
Name
*
First Name
Last Name
Title / Relationship
*
Contact Info for reference #3
*
Phone
Email Address
City
State / Province
Postal / Zip Code
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Criminal-Record Disclosure & Consent
Have you lived anywhere outside the state of Ohio at any time during the last five (5) years?
*
No
Yes — If “Yes,” list each state (or country) and the approximate dates you resided there. (One per line please)
Rows
State/Country
City (Optional)
From (MM/YYYY)
To (MM/YYYY)
Most Recent Location
Prior Location
Prior Location
Prior Location
Prior Location
Have you ever been convicted of, or pled "no contest" to, a criminal offense?
*
No
Yes (Please provide a brief explanation in the box below)
Explanation (offense, date, county, outcome)
*
e.g., Misdemeanor theft – Stark County – 03/2021 – completed probation
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Equal-Opportunity Notice:
Brewster Parke, Inc and Bel Air Care Center are a drug-free workplace and an equal-opportunity employer. We make employment decisions based on qualifications and business need. All qualified applicants will receive consideration without regard to race, color, religion, sex (including pregnancy, sexual orientation, and gender identity), national origin, age, disability, genetic information, ancestry, marital status, military or veteran status, or any other status protected by law.
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