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"Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me." Matthew 25:40
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Employment Application
Fairview Haven is committed to the highest level of quality and sets a high standard for our team members. Please read the below statements to ensure that your values align with the values and principles of Fairview Haven.
Mission Statement:
An Apostolic Christian Community where choice is valued, growth is encouraged, and life abounds
Vision Statement:
Putting the Gold Back into the Golden Years
How we apply these statements:
As a team member at Fairview Haven, you will respect the Holy Scriptures and God's Spirit among us and will try to uphold them and support their presence in the daily lives of the seniors we serve. You recognize you have a blessed privilege to serve these loved ones in their home.
As a team member at Fairview Haven, you will strive with the help of God to provide the highest quality of life to all we serve without regard to race, color, religion, or ability to pay.
As a team member of Fairview Haven, you will be committed to creating a home supporting the spiritual, physical, mental, and emotional needs of those we serve.
As a team member of Fairview Haven, you will honor the dignity of all residents and their right to make choices for themselves in a safe and nurturing environment.
As a team member of Fairview Haven, you will seek to enhance and embrace life, as well as provide support and care when the time of life's departure nears.
As a team member of Fairview Haven, you will strive to be a good steward of our residents' resources and seek to engage families and community in our mission of caring.
As a team member of Fairview Haven, you will value other team members and assist in creating an environment in which everyone can flourish and share in loving care.
I understand the above statements and my values align with the principles and values of Fairview Haven.
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Signature
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By typing your name, you are adding your signature.
Date
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Personal Information
Last Name
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First Name
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Middle Initial
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Street Address
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City
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State
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Zip Code
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Phone Number
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Secondary Phone Number
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Email
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Are you entitled to work in the United States?
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Yes
No
Fairview Haven complies with the Healthcare Worker Background Check Act, and your social security number is required to complete a background check before employment can be considered. This website is secure, and information included on this application is transmitted from this website via a secure method. If you are not comfortable submitting your social security number via this method, you MUST call Kristin at 815.692.6728 after you have submitted your application and provide your number before your application will be processed.
Social Security Number
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Individuals with disqualifying convictions, as listed in the Healthcare Worker Background Check Act, are prohibited from working in any position at Fairview Haven. Please review the following list:
Disqualifying Offense List
Have you ever been convicted of a disqualifying offence as listed on the Disqualifying Offense List?
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Yes
No
If yes, please explain:
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What position are you applying for?
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Choose Any
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Full-Time
Part-Time
PRN
Choose Any
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Days
Evenings
Nights
Expected Hourly Rate
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Date Available
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Professional License or Certification (RN, LPN, CNA, Etc)
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Date Received
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State
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License Number
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Has your license ever been suspended, revoked, or on probation for any reason?
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Yes
No
Who or how were you referred to Fairview Haven?
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If a current Fairview Haven employee referred you, please include their name so they can get a referral bonus.
Have you ever worked at Fairview Haven?
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Yes
No
When?
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Do you know anyone who lives/works at Fairview Haven? Who?
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What are your long range occupational goals?
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Education
High School - Name
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Last Year Complete - High School
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College/University - Name
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Last Year Complete - College
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Degree
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Major or Emphasis
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Other applicable education, special skills, training or proficiencies
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Prior Work Experience
**CNAs are required to provide employment history from the time of certification to the present**
Employer #1 (Current or Most Recent)
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Employer #1 City, State
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Employer #1 Phone Number
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Position - Employer #1
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Dates of Employment - Employer #1
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Reason for Leaving - Employer #1
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Name of Immediate Supervisor - Employer #1
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May We Contact - Employer #1
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Yes
No
Employer #2 (Prior)
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Employer #2 City, State
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Employer #2 Phone Number
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Position - Employer #2
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Dates of Employment - Employer #2
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Reason for Leaving - Employer #2
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Name of Immediate Supervisor - Employer #2
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May We Contact - Employer #2
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Yes
No
Employer #3 (Prior)
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Employer #3 City, State
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Employer #3 Phone Number
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Position - Employer #3
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Dates of Employment - Employer #3
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Reason for Leaving - Employer #3
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Name of Immediate Supervisor - Employer #3
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May We Contact - Employer #3
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Yes
No
To provide additional employment history, please upload your resume below.
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Max file size: 20MB
Personal References
**MUST provide 3 references who are NOT related to you**
Reference #1 Name
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Reference #1 Street Address
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Reference #1 City, State, Zip Code
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Reference #1 Phone Number
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Reference #2 Name
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Reference #2 Street Address
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Reference #2 City, State, Zip Code
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Reference #2 Phone Number
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Reference #3 Name
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Reference #3 Street Address
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Reference #3 City, State, Zip Code
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Reference #3 Phone Number
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Please review the information provided above before you continue. You will not be able to return to this page after you proceed to the next page.
By signing this application, I certify and affirm the following:
* that the information provided on this application is true and complete. I understand any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date.
* that employment will be conditioned upon successfully passing a pre-employment physical examination, fitness for duty examination, pre-employment drug screening, and criminal history check.
* that I am authorizing persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information.
* that my employment is at-will which means I may terminate the employment relationship at any time and for any reason with or without notice and that Fairview Haven has that same right. I understand no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized.
Signature
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By typing your name, you are adding your signature.
Date
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