Bethel Home and Services, Inc. Job Application
Contact us with any questions about this form, or to receive a paper copy
First Name *
Middle Name
Last Name *
Position Applying For *
Street Address *
Address Line 2
City *
State/Province/Region *
Zip Code *
Country *
Phone Number *
Example: (123) 456-7890
Email Address *
Gender *
Ethnicity *
Race *
Protected Veteran *
The definitions of protected veterans are listed below. Use the boxes following the definitions to indicate whether you are a protected veteran. Disabled veteran: A "disabled veteran" is one of the following: 1) a veteran of the U.S. military, ground, naval, or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or 2) a person who was discharged or released from active duty because of a service-connected disability. Recently Separated Veteran: A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service. Active Duty Wartime or Campaign Badge Veteran: An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval, or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. Armed Forces Service Medal Veteran: An "armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military , ground, naval, or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
Voluntary Self-Identification of Disability *
WHY ARE YOU BEING ASKED THIS QUESTION? Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities (Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligation of Federal contractors, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. Any answer you give will be kept private and will not be used against you in any way. HOW DO I KNOW IF I HAVE A DISABILITY? You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limit a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are limited to: blindness, deafness, cancer, diabetes, epilepsy, autism, cerebral palsy, HIV/AIDS, schizophrenia, muscular dystrophy, bipolar disorder, major depression, multiple sclerosis (MS), missing limbs or partially missing limbs, post-traumatic stress disorder (PTSD), obsessive compulsive disorder, impairments requiring the use of a wheelchair, intellectual disability (previously called mental retardation). REASONABLE ACCOMMODATION NOTICE: Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
How did you learn of this opportunity?
Are you available to work: *
What shift are you available: *
Have you been employed by Bethel Home and Services in the past? *
If yes, list dates of employment:
Clear selection
Clear selection
Are you legally eligible for employment in the United States? *
Proof of citizenship or immigration status will be required upon employment.
Have you ever been convicted of abusing, neglecting or mistreating individuals? *
In compliance with Federal regulations 42 CFR 483.13 (c)(1)(ii) and State statute (s.111.335(1)(c)(1).
Do you have pending charges or have you been convicted of a crime substantially related to the position for which you are applying? *
A criminal record does not necessarily disqualify an applicant from employment.
If you answered yes to question above, please explain:
A criminal record does not necessarily disqualify an applicant from employment.
Please list any education relevant to the position for which you are applying:
Please list any licensure or certifications relevant to the position for which you are applying:
What makes you a great candidate? *
Summarize special job-related skills & qualifications acquired from employment or other experiences.
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