Online Employment Application

If you are interested in a position, please fill out the following form:

Personal Information

Last Name:
First Name:
Middle Initial:
Social Security:
Street Address:
Street Address 2:
City:
State:
Zip Code:
Phone Number:
Cell Phone:
Email Address:

Department for which you are applying?
Date Available?
	Full Time Part Time
Which days if Part Time?
Shift Dining Services:	6AM-2:30PM 11AM-7:30PM 3:30PM-7:30PM
Shift Other Departments:	7AM-3PM 3PM-11PM 11PM-7AM

Were you previously employed by us?	Yes No
If Yes, when?
Name, if different during prior employment:

If you have not lived in the State of Pennsylvania for the last 24 months, list your previous addresses:
From:
To:
Street Address:
Street Address 2:
City:
State:
Zip Code:

From:
To:
Street Address:
Street Address 2:
City:
State:
Zip Code:

From:
To:
Street Address:
Street Address 2:
City:
State:
Zip Code:

Education Information

High School or GED
Name of School:
City, State or Country (if outside US):
Number of Years Attended:
Did you graduate?	Yes No

College
Name of School:
City, State or Country (if outside US):
Course of Study:
Number of Years Attended:
Did you graduate?	Yes No
Subjects Studied/Professional License:

Trade, Business, Correspondence School
Name of School:
City, State or Country (if outside US):
Course of Study:
Number of Years Attended:
Did you graduate?	Yes No
Subjects Studied/Professional License:

Work Experience

Most Recent Job
From:
To:
Name of Employer:
Phone of Employer:
Your Job Title:
Salary:
Reason For Leaving:
Prior Job
From:
To:
Name of Employer:
Phone of Employer:
Your Job Title:
Salary:
Reason for Leaving:
Prior Job
From:
To:
Name of Employer:
Phone of Employer:
Your Job Title:
Salary:
Reason for Leaving:

Special Skills

Subjects of study, experience, professional associations, memberships, equipment operation, languages, military training:

Physical Record

Are you able to perform the essential functions of the job for which you are applying either with or without accommodation?
	Yes No

Professional References

List three persons who have supervised or observed you at work.
Professional Reference 1
Name:
Address:
Phone Number:
Occupation:
Years Acquainted:
Professional Reference 2
Name:
Address:
Phone:
Occupation:
Years Acquainted:
Professional Reference 3
Name:
Address:
Phone Number:
Occupation:
Years Acquainted:

Personal References

List three persons not related to you whom you have known at least one year.
Personal Reference 1
Name:
Address:
Phone Number:
Occupation:
Years Acquainted:
Personal Reference 2
Name:
Address:
Phone:
Occupation:
Years Acquainted:
Personal Reference 3
Name:
Address:
Phone Number:
Occupation:
Years Acquainted:

Applicant's Statement

(Read carefully before agreeing.)

I certify that the facts set forth in this employment application are true and complete to the best of my knowledge. I understand that any false statements either by omission or commission, on or in this application, shall be considered sufficient cause for disqualification from further consideration for employment, and if I am employed, for discharge from employment.

I understand that a criminal history record and reference checks will be made if I am offered a position. Conviction of one or more crimes listed in the Older Adults Protective Services Act (a copy of which has been made available to me) will make me ineligible for employment. I swear and affirm that I am not disqualified from employment by reason of the Act.

I understand that employment is contingent upon my passing a physical examination, a negative drug screen, and a Mantoux test for tuberculosis and that all new employees are on a 3-month introductory period. I understand I may be required to work any shift.

I agree that, if employed, I will conform my conduct to the work rules established by Frederick Mennonite Community and understand that my employment can be terminated, with or without cause, by either Frederick Mennonite Community or myself.

My signature on this application certifies that I have no history of or conviction for violent crimes and never have been dismissed from employment due to the abuse of clients or residents.

Have you ever been dismissed from employment due to abuse of clients or residents?	Yes No
Do you have a history of or conviction for violent crime?	Yes No
Have you ever been convicted of a felony?(Conviction will not necessarily disqualify from employment.)	Yes No
Have you ever been excluded from a federal or state health care program? (This includes Medicare/Medicaid, and may include defaulting on a student loan?)	Yes No

Criminal Record Information and Statement

Chapter 25—criminal homicide
Section 2702—aggravated assault
Section 2901—kidnapping
Section 2902—unlawful restraint
Section 3121—rape
Section 3122.1—statutory sexual assault
Section 3123—involuntary deviate sexual intercourse
Section 3124.1—sexual assault
Section 3125—aggravated indecent assault
Section 3126—indecent assault
Section 3127—indecent exposure
Section 3301—arson and related offenses
Section 3502—burglary
Section 3701—robbery
Chapter 39—theft and related offenses (sections CC3901 – CC3934) (2 or more misdemeanors)
Section 4101—forgery
Section 4114—securing execution of documents by deception
Section 4302—incest
Section 4303—concealing death of a child
Section 4304—endangering welfare of children
Section 4305—dealing in infant children
Section 4952—intimidation of witnesses or victims
Section 4953—retaliation against witness or victim
Section 5902 (b)—felony prostitution and related offenses
Section 5903 (c) or (d)—obscene and other sexual materials and performances
Section 6301—corruption of minors
Section 6312—sexual abuse of children
P.L.233—felony under controlled substance, drug, device and cosmetic act.
A Federal or out-of-State offense similar in nature to those crimes listed above.

I swear and affirm that I have been given the opportunity to review the crimes enumerated herin, and that I am not disqualified from employment under the Older Adults Protective Services Act as a result of having been convicted of the listed offenses. I understand any false statements herin are subject to the penalties contained in 18 Pa. C.S. 4904, relating to unsworn falsification to authorities.

Reference Check Certification Consent Form

I understand that all statements made are subject to verification. I give permission to Frederick Mennonite Community to make any investigation of my personal employment history and authorize any former employer, person, firm, corporation, credit agency or government agency to give any information they have regarding me without liability. In exchange for the review of this employment application, I release all providers of information from any liability as a result of furnishing and receiving information.

Disclosure Statement

Frederick Mennonite Community is providing you with this document to disclose that a consumer report and/or investigative consumer report may be obtained for employment purposes as part of a background investigation of you and/or at any time while you work at Frederick Mennonite Community, should Frederick Mennonite Community authorize you to work with its residents and at its facility. An investigative consumer report may include information about your character, general reputation, personal characteristics or mode of living. These reports may include, but are not limited to, criminal background reports, credit reports, or social networking sites. The Fair Credit Reporting act provides you with the right to request, in writing within a reasonable amount of time, a disclosure of the nature and scope of the investigation requested. If any adverse action is taken based on the report(s) obtained, it is your right to have the name of the agency or agencies disclosed to you within the time allowed. You may also request a written summary of your rights under the Fair Credit Reporting Act.

According to the Fair Credit Reporting Act:
A person may not procure or cause to be prepared an investigative consumer report on any consumer unless it clearly and accurately discloses to the consumer that an investigative consumer report including information as to his character, general reputation, personal characteristics and mode of living and employment history, whichever are applicable, may be made.

Frederick Mennonite Community has provided you with this Disclosure in accordance with the provisions of the Fair Credit Reporting Act.

At Will

All employees who do not have an individual written employment contract for a specified period of time are employed at the will of the facility for an indefinite period of time. Employees hired "at-will" may resign at anytime without cause, and without notice, and the facility may terminate the employee at any time without cause and with or without notice. Disciplinary action noted throughout the handbook is not all inclusive and does not restrict the facility's right to terminate "at-will" status, or in any way alter or change the facility's right to terminate such employee.

What is the Reason for applying at Frederick Living?

(List as many reasons as apply)

How did you find out about Frederick Mennonite Community?

Newspaper Ad

Boyerstown Times

Hearthstone Town & Country

Pottstown Mercury

The Reporter

Reading Eagle Times

Other

The Sign out in front of Frederick Living

Someone told me

A Frederick Employee

Someone Else

Internet Ad

Other - Please explain

By submitting your information this application will be considered completed and signed by you.

Frederick Living does not discriminate on the basis of race, gender, color, national origin or handicap.

Residential Living • Personal Care • Memory Support • Skilled Nursing • Adult Day Care