Personal Care Aide

Application Date*

Date Available to Start Work*

Personal Information

Name*

First Last

Applicant's Address*

Street Address City State ZIP Code

Primary Phone*

Secondary Phone

Location Applying For*

Position(s) Applied For*

Rate of Pay Desired*

Position Type*

Full-time

Part-time

Shift*

Please indicate hours of availability.

How did you learn about this position?*

If referred by a current employee, please tell us their name so we can thank them.*

Please write N/A if not referred by current employee.

Are You 18 Years of Age or Older?*

Yes

Are You a U.S. Citizen or Resident Alien with a Visa Allowing You to Work?*

Yes

Have You Ever Applied to This Company Before?*

Yes

When did you last apply?

Are You Related to Anyone Currently Working at Baptist Village Communities?*

Yes

Name of Related Person

Church Member*

Yes

Name of Church

Do you use tobacco, illegal drugs or alcoholic beverages?*

Yes

If yes, please specify

References

(do not include relatives or former employers)

Name and Occupation*

Address*

Phone Number*

Name and Occupation*

Address*

Phone Number*

Name and Occupation*

Address*

Phone Number*

Education and Training

Name of High School*

Location*

Grade Completed*

Year and Degree*

Name of College

Location

Year Completed

Year and Degree

Other Education/Training

Location

Grade/Year Completed

Year and Degree

Employment and Record

(list last or present position first) If any breaks or gaps in employment exist, please briefly explain below.

Employer 1*

Address*

Street Address City State ZIP Code

Supervisor

Phone*

Currently Employed

Date Employed From*

Date Employed To*

Starting Salary Range*

Ending Salary Range*

Position and Duties*

Employer 2

Address

Street Address City State ZIP Code

Supervisor

Phone

Date Employed From

Date Employed To

Starting Salary Range

Ending Salary Range

Position and Duties

Employer 3

Address

Street Address City State ZIP Code

Supervisor

Phone

Date Employed From

Date Employed To

Starting Salary Range

Ending Salary Range

Position and Duties

Employer 4

Address

Street Address City State ZIP Code

Supervisor

Phone

Date Employed From

Date Employed To

Starting Salary Range

Ending Salary Range

Position and Duties

Employer 5

Address

Street Address City State ZIP Code

Supervisor

Phone

Date Employed From

Date Employed To

Starting Salary Range

Ending Salary Range

Position and Duties

If your former employment references, education or military service are under a name other than indicated on front of application, please indicate:*

(If not applicable, put N/A)

May we contact your present employer at this time?*

Yes

Professional Licenses and/or Certification

Type

Organization or State

Date Issued

Number

Verification

Type

Organization or State

Date Issued

Number

Verification

Type

Organization or State

Date Issued

Number

Verification

Office Skills

Please list all computer/software programs you are experienced in*

Example: Word, Excel, Outlook, PowerPoint, Publisher, Access, etc...

Writing/Editing*

Fair

Good

Excellent

Office Equipment

(If not applicable, put N/A)

Why are you applying for a position in this ministry with senior adults?*

Are you a US Military Veteran?

Employment Acknowledgment

(please read and sign)

Baptist Village Communities does not discriminate in its hiring decisions or in any other employment decision on the basis of race, color, sex, 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.

As part of the application process, I voluntarily give Baptist Village Communities the right to make a thorough investigation of my past employment background and activities. I further agree to cooperate fully in such investigation. I hereby release from all liability and responsibility any and all persons, companies or entities which provide Baptist Village Communities with information or documents requested by Baptist Village Communities as part of the application process.

If I am hired by the company, I understand that my employment will be "at will," meaning either party - me or the company - will be able to terminate my employment at any time, with or without cause. I also understand that my employment may be terminated for any misstatement of fact appearing on, or omission of fact from, this application form.

Further, I understand that after I am given a conditional offer of employment, I may be required to undergo a physical examination as well as a background check screening as a prerequisite to my continued employment with the company. I hereby consent to take that physical examination and any such future physical examinations as are required by the company.

Finally, I understand that I, like every other employee of this company, will be required to complete an Employment Verification Form (I-9) within three (3) days of my employment. At that time, I will produce the documentation of my choosing which will satisfy the requirements stated on the I-9 form for proof of identity and eligibility for employment.

Signature*

First Middle Last

Application Acknowledgement Date*

CAPTCHA

If your application is submitted successfully, you will receive a confirmation notification.

Please watch for notification of successful submission.

Uniform Employment Application for Nurse Aide Staff (Effective November 1, 2012)

This application form is required by Title 63 O.S. § 1-1950.4 of state law and by the Oklahoma State Board of Health Rules OAC 310-2-15-3. This uniform application shall be used as the only application for employment of nurse aides in nursing and specialized nursing facilities, residential care homes, assisted living centers, continuum of care facilities, hospice programs, adult day care centers and home care agencies.

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.

ATTENTION NURSE AIDES: RETURN YOUR COMPLETED APPLICATION TO EMPLOYER.

Date of Application*

Date Available to Start Work*

How did you learn about this position?*

Location of Work Requested*

If referred by a current Baptist Village employee, please tell us their name so we can thank them.*

First Name Last Name

Write N/A if not referred by current employee.

1. Personal Information

Name*

First Middle Last

Last 4 of Social Security Number:*

List any other name(s) you have previously worked under, such as maiden name:*

Present Address*

Street Address City State ZIP Code

Permanent Address (if different than present address)

Street Address City State ZIP Code

Telephone #*

Date of Birth:*

Sex*

Male

Female

Race

For purposes of Criminal History Records Search

Emergency Contact Person

Name*

First Last

Address*

Phone Number*

2. Employment Desired

Position Applied For*

Salary Required*

Hours available to work*

Days

Evenings

Nights

Weekends

Will you accept employment of*

Full Time

Part Time

Occasional Part Time

3. U.S. Military Record

Branch

Date Entered

Date Discharged

Type of Discharge

Prior Work History

List your last four (4) jobs beginning with your most recent or current employer.

Employer's Name*

Telephone Number*

Employer's Address*

Street Address City State ZIP Code

Position Held*

Supervisor*

Dates Employed: From (month/year)*

To (month/year)*

Salary*

Reason for Leaving*

Employer's Name

Telephone Number

Employer's Address

Street Address City State ZIP Code

Position Held

Supervisor

Dates Employed: From (month/year)

To (month/year)

Salary

Reason for Leaving

Employer's Name

Telephone Number

Employer's Address

Street Address City State ZIP Code

Position Held

Supervisor

Dates Employed: From (month/year)

To (month/year)

Salary

Reason for Leaving

Employer's Name

Telephone Number

Employer's Address

Street Address City State ZIP Code

Position Held

Supervisor

Dates Employed: From (month/year)

To (month/year)

Salary

Reason for Leaving

List name(s) of all other employers for the last five (5) years:

May we contact your present employer?*

Yes

Not Applicable

Have you ever been terminated or asked to resign from any position?*

Yes

If yes, provide reason.

5. Educational Background

List all educational schools attended with degrees, diplomas or certificates received.*

Name of Institution (High School, Technical School, College)

Type of Studies

Dates Attended & Diplomas, etc.

If your school or employment records are under another name(s), indicate that name(s):

7. References

List name, address and telephone number of three (3) references who are not relatives or former employers.*

8. 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:

State and/or jurisdiction.
Nature of complaint/offense
Disposition of complaint and/or offense (e.g., "dismissed insufficient evidence", "deferred sentence").
Date of disposition
Attach copy of any correspondence received by you, the applicant, regarding the complaint/offense.

a. Have you ever: 1) participated in a first offender program; 2) deferred adjudication or other program or arrangement where adjudication has been withheld; 3) pied guilty or no contest; 4) been convicted; 5) received a deferred sentence; and/or 6) been sentenced for any criminal offense in any state or US jurisdiction regardless of whether this matter has been expunged or otherwise removed?*

Yes

Explain

b. Have you ever been found in violation of any state, US jurisdiction, or federal law regulating the practice of a health care profession?*

Yes

Explain

c. Are any disciplinary actions or allegations, pending or substantiated, against you or your CNA certification or health care professional license in any state or U.S. jurisdiction?*

Yes

Explain

d. 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?*

Yes

Explain

10. Previous CNA Training (Complete this section only if you will require training.)

Please complete the following if you have had CNA Training in the past for any of these categories: LTC, HH, ADC, RC, or DDDC.

11. Important Information for the Job Applicant

Are you a US Military Veteran?

It is unlawful for any person to provide false information regarding a criminal conviction on this uniform employment application for nurse aides. Providing false information regarding a criminal conviction is a misdemeanor under Title 63 of the Oklahoma Statutes, Section l-1950.4a. Providing false information about a criminal conviction on this application is punishable by a fine not to exceed Five Hundred Dollars ($500.00), by imprisonment in the county jail for a term of not more than one (1) year, or by both such fine and imprisonment.

NOTICE

I UNDERSTAND PROVIDING FALSE OR MISLEADING INFORMATION TO A TRAINING PROGRAM, A FACILITY, OR THE DEPARTMENT IS GROUNDS FOR DENIAL, SUSPENSION, WITHDRAWAL, AND/OR NONRENEWAL OF CERTIFICATION. I ALSO UNDERSTAND PROVIDING FALSE INFORMATION OR OMISSION OF FACTS MAY DISQUALIFY ME FROM EMPLOYMENT AND MAY CAUSE TERMINATION IF DISCOVERED AT A LATER DATE.

INITIAL HERE*

I certify I have read and completed this application and that the information I have provided on this application is true and complete.

This field is hidden when viewing the form

I certify I have read and completed this application and that the information I have provided on this application is true and complete.

Signature of Applicant

Date of Signature

12. Criminal Arrest Check List

Effective November 1, 2012, and in accordance with public law, Title 63 of the Oklahoma Statutes, Section 1-1950.1, employment at this employer shall not be considered if the below signed individual has been convicted of, pied guilty or no contest to, or received a deferred sentence for, a felony or misdemeanor offense for any of the following offenses in any state or federal jurisdiction, as stated by Oklahoma Statute, Section 1-1950.l(C)(l) of Title 63:

abuse, neglect or financial exploitation of any person entrusted to the care or possession of such person,
rape, incest or sodomy,
child abuse,
murder or attempted murder,
manslaughter,
kidnapping,
aggravated assault and battery,
assault and battery with a dangerous weapon, or
arson in the first degree.

Effective November 1, 2012, and in accordance with public law, Title 63 of the Oklahoma Statutes, Section 1-1950.1, employment at this employer shall not be considered for the below signed individual if less than seven (7) years have elapsed since the completion of sentence', and the results of a criminal history check reveal that the subject person has been convicted of, or pied guilty or no contest to, a felony or misdemeanor offense for any of the following offenses, in any state or federal jurisdiction, as stated by Oklahoma Statute, Section 1-1950.l(C)(2) of Title 63:

assault,
battery
indecent exposure and indecent exhibition, except where such offense disqualifies the applicant as a registered sex offender,
pandering,
burglary in the first or second degree,
robbery in the first or second degree,
robbery or attempted robbery with a dangerous weapon, or imitation firearm,
arson in the second degree,
unlawful manufacture, distribution, prescription, or dispensing of a Schedule I through V drug as defined by the Uniform Controlled Dangerous Substances Act,
grand larceny, or
petit larceny or shoplifting.

Pursuant to 63 O.S. § 1-1950.l(A)(5), "Completion of the sentence" means the last day of the entire term of the incarceration imposed by the sentence including any term that is deferred, suspended or subject to parole.

It is further understood that if I am hired, it will be as a temporary employee until the employer receives my criminal background check. 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 I have no disqualifications for employment as described above and specified in Title 63 of the Oklahoma Statutes, Section 1-1950.l(C). My signature below authorizes the employer to run a check with the Nurse Aide Registry of the Oklahoma State Department of Health for notations of abuse, neglect or misappropriation of resident's property. I hereby give the Oklahoma State Bureau of Investigation authority to proceed with a criminal history records check as authorized by Title 63 of the Oklahoma Statutes, Section 1- 1950.l(B).

This field is hidden when viewing the form

I hereby certify I have no disqualifications for employment as described above and specified in Title 63 of the Oklahoma Statutes, Section 1-1950.l(C). My signature below authorizes the employer to run a check with the Nurse Aide Registry of the Oklahoma State Department of Health for notations of abuse, neglect or misappropriation of resident's property. I hereby give the Oklahoma State Bureau of Investigation authority to proceed with a criminal history records check as authorized by Title 63 of the Oklahoma Statutes, Section 1- 1950.l(B).

Signature of Applicant

Date of Signature

CAPTCHA

Personal Information

References

Education and Training

Employment and Record

Professional Licenses and/or Certification

Office Skills

Employment Acknowledgment

If your application is submitted successfully, you will receive a confirmation notification.

Uniform Employment Application for Nurse Aide Staff (Effective November 1, 2012)

1. Personal Information

Emergency Contact Person

2. Employment Desired

3. U.S. Military Record

Prior Work History

5. Educational Background

6. Certification

7. References

8. Background Information

9. Applicant's Certification and Agreement

10. Previous CNA Training (Complete this section only if you will require training.)

11. Important Information for the Job Applicant

I certify I have read and completed this application and that the information I have provided on this application is true and complete.

12. Criminal Arrest Check List

Personal Care Aide

Baptist Village Application for General Use

Personal Information

References

Education and Training

Employment and Record

Professional Licenses and/or Certification

Office Skills

Employment Acknowledgment

If your application is submitted successfully, you will receive a confirmation notification.

Uniform Employment Application for Nurse Aide Staff (Effective November 1, 2012)

Uniform Employment Application for Nurse Aide Staff (Effective November 1, 2012)

1. Personal Information

Emergency Contact Person

2. Employment Desired

3. U.S. Military Record

Prior Work History

5. Educational Background

6. Certification

7. References

8. Background Information

9. Applicant's Certification and Agreement

10. Previous CNA Training (Complete this section only if you will require training.)

11. Important Information for the Job Applicant

I certify I have read and completed this application and that the information I have provided on this application is true and complete.

12. Criminal Arrest Check List