Fairport Baptist Homes* | employment application

Contact Information

Fairport Baptist Homes is an equal opportunity employer and does not discriminate because of race, creed, color, national origin, religion, age, sex, disability, sexual orientation, marital status, military status, genetic predisposition or carrier status, or any other status protected by law. No questions on this application are asked for the purpose of limiting or excluding any applicant’s consideration for employment. Fairport Baptist Homes hires qualified individuals regardless of disability and will reasonably accommodate an individual’s disability during the application process and on the job. Such employees are encouraged to request a reasonable accommodation when necessary.

Name*

First Middle Last

Application Date*

Address*

Street Address Address Line 2 City State ZIP Code

Phone Numbers

If you need additional rows, please click the + below.

Select a Type	Please enter your phone number

Email*

Have you ever worked for the Homes under a different name?*

Is additional information relative to change of name, use of an assumed name or nickname necessary to enable check on your work records?

Yes
No

Explain...*

Position or type of work desired:

I am available to work:*

Full Time
Part Time
Per Diem
Shift Preference
I can work weekends
I can work on holidays

Are you 18 years of age or older?*

Yes
No

Have you previously applied to Fairport Baptist Homes?*

Yes
No

If yes, what position?

When would you be available to start?

Please list any relatives/friends that work at Fairport Baptist Homes

Education

Schools Attended

If you need additional rows, please click the + below.
Please provide a list of schools or universities attended.

School	Name and Address of School	Last Year Attended	Diploma Degree	Course of Study

Nursing/Professional License/Certification No. and Type

If you need additional rows, please click the + below.
* If you cannot provide your CNA Certification number with your application, you will be asked to supply it during our follow-up interview / conversation.

License Name	Date	CNA Certification # *

Have you ever been found guilty of unprofessional misconduct, or negligence in any profession?*

Yes
No

Are charges now pending against you for unprofessional conduct, professional misconduct, or negligence in any profession?*

Yes
No

Have you ever surrendered any license in lieu of disciplinary procedure?*

Yes
No

If “Yes” answered to any of the above three questions, please explain.

Are you legally entitled to work in the U. S.?*

Yes
No

Have you ever been convicted of a crime (other than traffic violation)?*

Yes
No

If yes, please explain:

Note: Prior criminal conviction is not necessarily a bar to employment.

Were you previously employed by any program of Fairport Baptist Homes?*

Yes
No

If yes, please give dates:

Have you ever worked at FBH through an agency or temporary agency?*

Yes
No

Employment Experience

Please list all previous employers for the last 10 years.

If you need additional rows, please click the + below.
Starting with your current employer, please provide each field with information as requested below.

Employer Name	Address	Phone	Dates (MM/YY)	Base Pay Rate?	Paid How Often?	Reason for Leaving	Your Title	Description of Responsibilities

Professional References

Please provide employment contacts and references

If you need additional rows, please click the + below.
(Please do not list friends or family members)

Name	Address / Phone	Number of Years Known	Nature of Relationship

I authorize Fairport Baptist Homes to verify the accuracy of information provided on this application and to obtain reference information on my work performance. I hereby release Fairport Baptist Homes, and any party supplying references, from any liability for an employment decision based on such information.

With regard to my current employer, Fairport Baptist Homes:*

may contact my current employer.contact my current employer.
may NOT contact my current employer.

Authorization for the Fairport Baptist Homes, to review any and all records pertaining to my background and criminal history*

I agree and give my permission.
I do NOT agree and do NOT give my permission.

Without permission to review your background, we can not submit this application.

Signature*

Please sign below by typing your full legal name followed by the date in the following format: Name - MM.DD.YYYY

Name

This field is for validation purposes and should be left unchanged.

employment application

Contact Information

Education

Employment Experience

Professional References

Without permission to review your background, we can not submit this application.

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