• Employee Health Benefits • Flexible Work Schedules •

							                                                                             Application for Employment
                                                                            Briarfield Health Care Centers

Dear Applicant,

Thank you for your interest in working for Briarfield Health Care Centers.
Some of the items we are proud to offer our employees include:

•   Employee Health Benefits
•   Flexible Work Schedules
•   Seven Seventeen Credit Union Membership
•   401K Retirement Plan with Employer Contributions
•   Uniform Allowance
•   Paid Vacation
•   Paid Personal Days
•   Paid Holidays/Premium Holiday Pay

Please fill out your application as completely as possible, and we will be happy to keep it on file for one year.

Again, Thank you for your interest in joining our team.

We consider applicants for all positions without regard to race, color, religion,creed, gender, national origin, age, marital or veteran status, or any other legally protected status.



Position(s) Applying for:__________________________________________________________________

Date of Application:__________________

How did you learn about us?:    Advertisement  Employment Agency   Relative  Freind   Inquiry  Other
if other please explain. _____________________________________________________________________________________________
______________________________________________________________________________________________________________

Last Name_____________________________                                        First Name____________________________                                         Middle Name_________________

Address______________________________                                         City________________________              State________                                              Zip Code_________
Telephone Number: _____________________                                       Social Security Number (voluntary)_________________________

Best time to contact you at home is:_________________________
If you are under 18 years of age, can you provide required proof of your eligibility to work?___________________________________________


Have you ever been employed with us before?  Yes     No
If yes, give date:__________________________________

Do any if your friends or relatives, other than a spouse, work here?                                 Yes            No
Are you currently employed?         Yes       No

May we contact you present employer?                        Yes            No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? (Proof of citizenship or immigration
status will be required upon employment)    Yes        No

Date available for work: _____________________________________________
What is your desired salary range?______________________________________

Are you available to work:                   Full-Time (please indicate 1 2 3 shift)
                                             Part-Time (please indicate Mornings Afternoons Evenings)
                                             Temporary (please indicate dates available: )

Are you currently on "lay-off" status and subject to recall?                              Yes           No
Can you travel if a job requires it?  Yes     No
Education:
                             Name of School                  Course of Study                    Completed                 Degree

Elementary School:         _________________________________________________________________________________________

High School:               _________________________________________________________________________________________

Undergraduate College:     _________________________________________________________________________________________

Graduate Professional:     _________________________________________________________________________________________

Other (Specify)

Describe any specialized training, apprenticeship, skills and extra-curricular activities: _________________________________________________
______________________________________________________________________________________________________________

Describe any job-related training received in the United State Military: ____________________________________________________________
______________________________________________________________________________________________________________

Experience:

Employer:___________________________________                 Dates Employed:_______________             Work Performed:______________

Address: ________________________________________
Telephone Number: ________________________________
Job Title: ________________________________________
Supervisor: _______________________________________
Hourly Rate/Salary: _______________   Starting/Final_____________
Reason for Leaving:_______________________________________________________________________________________________
______________________________________________________________________________________________________________


Employer:___________________________________                 Dates Employed:_______________             Work Performed:______________

Address: ________________________________________
Telephone Number: ________________________________
Job Title: ________________________________________
Supervisor: _______________________________________
Hourly Rate/Salary: _______________   Starting/Final_____________
Reason for Leaving:_______________________________________________________________________________________________
______________________________________________________________________________________________________________

Employer:___________________________________                 Dates Employed:_______________             Work Performed:______________

Address: ________________________________________
Telephone Number: ________________________________
Job Title: ________________________________________
Supervisor: _______________________________________
Hourly Rate/Salary: _______________   Starting/Final_____________
Reason for Leaving:_______________________________________________________________________________________________
______________________________________________________________________________________________________________

Employer:___________________________________                 Dates Employed:_______________             Work Performed:______________

Address: ________________________________________
Telephone Number: ________________________________
Job Title: ________________________________________
Supervisor: _______________________________________
Hourly Rate/Salary: _______________   Starting/Final_____________
Reason for Leaving:_______________________________________________________________________________________________
______________________________________________________________________________________________________________
List professional, trade, business or civic activities and offices held: _______________________________________________
(You may exclude membership which would reveal gender, race, religion,            _______________________________________________
national origin, age, ancestry, disibility, or any other legally protectd status) _______________________________________________
                                                                                  _______________________________________________
                                                                                  _______________________________________________

Summarize special job-related skills and qualifications acquired from employment or other experience: ____________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Specialized Skills (check skills/equipment operated):

   Terminal
    PC/MAC
   Typewriter
__________WPM

    Spreadsheet
    Word Processing
    Shorthand
__________WPM

      Production/Mobile Machinery (list):____________________________________________________________________

      Other (list):______________________________________________________________________________________

State any additional information you feel may be helpful to us in considering your application:__________________________________________
______________________________________________________________________________________________________________

Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE
REQUIREMENTS OF THE JOB IN WHICH YOU ARE APPLYING.

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation,
the activities involved in the job or occupation for which you have applied? A review of the activities
involved in such a job or occupation has been given.            Yes       No

References:

Name: __________________________                 Address: _______________________________________                 Phone Number:_______________

Name: __________________________                 Address: _______________________________________                 Phone Number:_______________

Name: __________________________                 Address: _______________________________________                 Phone Number:_______________

Name: __________________________                 Address: _______________________________________                 Phone Number:_______________

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employment necessary in arriving at an employement decision.

This application for employment shall be considered active for a period of time not to exceed 365 days. An applicant wishing to be considered for
employment beyond this time period should inquire as to wether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at
will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is
further understood that this "at will" employment relationship may not be changed with any written document or by
conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview may result in discharge. I under-
stand, also, that I am required to abide by all rules and regulations of the employer.


Signature:___________________________________________________                         Date:_________________________________