Application for Employment
Promoting Hope, Dignity, and Purposeful LivingIt is our policy, in accordance with applicable federal and state laws, not to discriminate on the basis of race, creed, color, religion, sex, national origin, age, handicap, disability, marital status, sexual orientation, or status as a Vietnam-era or special disabled veteran.
Applying For: Heritage Village Rehab & Skilled Nursing, Inc. Heritage Park Rehab & Skilled Nursing Heritage Green Rehab & Skilled Nursing Heritage Village Retirement Campus Heritage Ministries Management Co. Orchard Grove at the Woodlands *
PhilosophyHeritage Ministries is an accredited human service ministry of The Free Methodist Church of North America. Our mission is rooted in values as found in the Holy Scriptures. Our vision and mission are inspired from, and empowered by, the Word of God.We believe in the sanctity and value of human life in all of its stages, from birth through adult. All humans are created in the image of God, and are worthy of redemption through the death and resurrection of His Son, Jesus Christ. We believe that all who are served by our organization have the freedom to exercise their God-given rights to dignity, respect, and the highest possible quality of care without discrimination. We believe in, and encourage all of our healthcare residents to consider the preparation of Advance Directives. However, we also believe there is no justification for euthanasia or physician-assisted suicide, and will not permit these practices within our facilities.The core values that direct our behavior, decision-making, work ethic, and the care we provide all individuals who utilize our services flow from our desire to glorify God, and model the life of Jesus Christ as we live out the principles of Scripture.Mission StatementTo SERVE others through Christ-centered ministries which promote hope, dignity, and purposeful living
Vision StatementHeritage Ministries will be a trusted leader in the provision of human services that model God's love.
Personal Information
Last Name: *
First Name: *
Middle Initial: *
Have you ever been known or employed by another name? Yes No *
Other Name Known By
Personal Address Line 1: *
Personal Address Line 2:
City: *
State: *
Zip Code: *
Telephone Number: *
Alternate Telephone:
Email Address
Are you prevented from lawfully becoming employed in the United States due to Visa or Immigration Status? (Proof of citizenship or immigration status will be required upon employment.) Yes No *
Are you over 18 years of age? Yes No *
If not, can you provide proof of your eligibility to work? Yes No
Briefly, why would you like to become employed by Heritage Ministries? (500 chars left) *
How did you learn about our organization? *
Personal Information (Continued)
Have you ever been employed by Heritage Ministries? Yes No *
Facility Name:
Start Date:
End Date:
Reason For Discontinuing Employment? (100 chars left)
Do you have any friends or relatives that currently work for Heritage Ministries? Yes No *
If Yes, please list names and relationships: (200 chars left)
Have you ever filed an application with Heritage Ministries in the past? Yes No *
If Yes, please provide dates:
Have you ever been convicted of a crime? Yes No *
If yes, please explain: (200 chars left)
Employment Interests
Please specify the position for which you are applying: *
Are you currently employed? Yes No *
If Yes, may we contact your current employer? Yes No
On what date would you be available for work? *
Shift Preference: Full-Time Part-Time Occasional/On Call Any of the above *
Shift Time Preference: Days Evenings Nights *
Locations Preference: Heritage Village Rehab & Skilled Nursing, Inc- Gerry, NY Heritage Park Rehab & Skilled Nursing- Jamestown, NY Heritage Green Rehab & Skilled Nursing-Greenhust,NY Heritage Village Retirement Community-Gerry,NY Heritage House Childcare & Learning Center-Jamestown,NY *
Please explain any scheduling restrictions you may have: (200 chars left)
If necessary, are you willing to travel for temporary work assignments at the various locations listed above? Yes No *
Can you successfully perform the functions of the job for which you are applying with or without reasonable accomodations? Do not answer this question unless you have been informed about the requirements of the position for which you are applying. A job description can be provided if you so desire. Yes No
Are you available weekends and Holidays? Yes No *
Skills
Please choose Computer Fax Calculator Switchboard Transcription Email Microsoft Word Excel Powerpoint Publisher Acess
Nursing Certification Information
Nurse Aide Certification Number:
Expiration Date:
Training Received at Facility: (100 chars left)
Facility Address:
Training Date:
Professional License Number:
Pro Expiration Date:
Employment History
Please provide a complete employment history, starting with your present or most recent employer.
Employer 1 Information
Company Name: *
Company Address: *
Name of Supervisor: *
Final Wage: *
Dates Employed From: *
Description of Job Duties: (200 chars left) *
Reason for Leaving? (100 chars left) *
Employer 2 Information
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Company Name:
Company Address:
City:
State:
Zip Code:
Telephone Number:
Name of Supervisor:
Final Wage:
Dates Employed From:
Description of Job Duties: (200 chars left)
Reason for Leaving? (100 chars left)
Employer 3 Information
Employer 4 Information
High School Education Information
High School Name: *
High School Address: *
Did You Graduate? Yes No *
Academic Major:
Academic Degree:
College Information
College 1 Name:
College 1 Address:
Did You Graduate? Yes No
College 2 Name:
College 2 Address:
College 3 Name:
College 3 Address:
Trade or Technical School
Institution 1 Name:
Institution 1 Address:
Institution 2 Name:
Institution 2 Address:
References
Please provide character or work related references. No family references are accepted.
Reference 1 Name:
Reference Address:
Reference Phone:
Reference Email Address:
Reference 2 Name:
Reference 3 Name:
Reference 4 Name:
US Military Services
Branch of Military Service:
Military Schools Attended:
Area of Specialization:
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