Masonic Village at Burlington Acacia Hospice Services

APPLICATION FOR EMPLOYMENT

The Masonic Charity Foundation is an equal opportunity employer and does not unlawfully discriminate in employment. No question on this

application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state,

or federal law. Equal access to employment, services, and programs are available to all persons. Those applicants requiring reasonable

accommodation to the application and/or interview process should notify the Human Resources Department.

PLEASE PRINT

Date __________________ Email ____ _______________

Name

Last First Middle

Address

Street City State Zip

Primary Phone _______ Alternate Phone _______________________

Are you a student? Yes No If employed and you are under 18, can you furnish a work permit? Yes No

Are you a United States citizen or otherwise authorized to work in the U.S. on an unrestricted basis? Yes No

(Verification will be required)

Position(s) applying for Full Time Part Time No preference

Shift desired: Date Available to Begin Work Salary Desired

I am NOT available to work the following days and/or times:

Are you currently employed? Yes No If yes, may we inquire to your present employer? Yes No

Have you ever been employed by the Masonic Charity Foundation, Masonic Village at Burlington (formerly Masonic Home of NJ) or

Acacia Hospice Services? Yes No

If yes, when? Name of Supervisor

Reason for leaving

Do you have any relatives working at the Masonic Village at Burlington? _______ Name ___________________________________________

How did you learn of this job opportunity? __________________________________________________________________________________

Did a current employee of the Masonic Village at Burlington refer you? ______________

First and last name of employee: _____________________________________________________________________________________

902 JACKSONVILLE ROAD ●BURLINGTON, NEW JERSEY 08016-3896 ●609-239-3900 ●FAX 609-239-3905

EMPLOYMENT

Beginning with your PRESENT OR MOST RECENT employment, list ALL positions held. Clearly describe the work (duties) you

personally performed. You must fill out this application completely even if a resume is being attached.

Present or Most Recent Employer Job Title Salary or Wage

Address

Dates Employed

From:

To: City/State/Zip

Telephone Number

Name of Supervisor Reason for Leaving

Job Duties:

Employer Job Title Salary or Wage

Address

Dates Employed

From:

To: City/State/Zip

Telephone Number

Name of Supervisor Reason for Leaving

Job Duties:

Employer Job Title Salary or Wage

Address

Dates Employed

From:

To: City/State/Zip

Telephone Number

Name of Supervisor Reason for Leaving

Job Duties:

Employer Job Title Salary or Wage

Address

Dates Employed

From:

To: City/State/Zip

Telephone Number

Name of Supervisor Reason for Leaving

Job Duties:

EDUCATION

School Name & Address Course of Study Grade

Completed

Degree

COLLEGE

HIGH SCHOOL

LPN’s and RN’s please provide name of school when you received your degree, if not listed above:

Describe specialized training, skills and/or list health care, business or industrial equipment operated:

License(s) and/or Certification(s) held:

Type: ___________________ Number: ____________________________________ Expiration: ________________________ State: __________________

Type: ___________________ Number: ____________________________________ Expiration: ________________________ State: __________________

Type: ___________________ Number: ____________________________________ Expiration: ________________________ State: __________________

Have you been a CNA in another state? Yes No If Yes, what state? ____________________________

REFERENCES

Please give the names and phone numbers of three (3) references. DO NOT LIST RELATIVES.

Name Telephone Years Known

Name Telephone Years Known

Name Telephone Years Known

APPLICANT’S STATEMENT

I understand that the Masonic Charity Foundation follows an employment-at-will policy, in that the employer or I

may terminate any employment any time, or for any reason consistent with applicable state or federal law. I understand that

this application is not a contract of employment. I understand that to be employed, I must be lawfully authorized to work in

the United States and I must show the employer documents that will provide this if I am offered the job.

I understand that the Masonic Charity Foundation will thoroughly investigate my work and personal history and

verify all data given on the application, on related papers, and in any interview. I authorize all individuals, schools and firms

named within to provide any information requested about me and I release them from all liability for damages in providing

this information.

I understand that I am required to abide by all policies, rules and regulations of the Masonic Charity Foundation and

agree to take a post-offer physical examination including a Mantoux (TB) test or chest x-ray, as required, and a drug test.

I understand that consideration of my employment with the Masonic Charity Foundation is contingent upon

completion of an authorized criminal background check which will be conducted following an initial interview, should one be

conducted. While a conviction(s) will not necessarily disqualify an applicant from employment, the Masonic Charity

Foundation may refuse to consider for employment any applicant who refuses to consent to a criminal background check.

Convictions that have been expunged or pardoned will not be considered by the Masonic Charity Foundation.

I certify that all statements herein are true and understand that any falsification or willful omission shall be sufficient

cause for dismal or refusal of employment.

Applicant’s Signature Date

EMPLOYER USE ONLY

TO BE COMPLETED BY DEPARMENT HEAD:

Position Dept. Budget Code

Hourly Rate Hours per pay period Access Level

Shift/Hours Status: FT FTB PT VARIABLE OC Weekend Program

New Position No Yes Req # Replacing

Additional Hiring Requirements: ______________________________________________________________________

Department Head/Hiring Director Signature Date

HUMAN RESOURCE USE ONLY

Approved to Hire: __________________________________ Date: ______________________

Human Resources Director

Date of Job Offer Start Date PIN #

Drug Test Physical Back Test

1st Mantoux 2nd Mantoux X-Ray (if applicable)

Rubella Titer _________________ Rubeola Titer _______________

Other _________________________________________________________________

Comments:

HR Recruiter Notes: ________________________________________________________________________________

__________________________________________________________________________________________________

REV. 2/2015

PRE-INTERVIEW QUESTIONNAIRE

Resumes and applications provide us with useful information but we find that is also helpful to provide candidates

with an opportunity to provide additional information. Please help us understand you better by answering these

questions. It’s important that you answer the questions honestly, so that we can accurately assess your “fit” with

this job and the organization.

NAME: DATE:

POSITION APPLYING FOR:

1. WHAT IS THE PRIMARY REASON YOU ARE APPLYING FOR THIS POSITION?

2. WHAT ARE THE TWO MOST IMPORTANT THINGS IN YOUR OPINION THAT THE MASONIC HOME DOES?

3. WHAT CHARACTERISTIC(S) DO YOU POSSESS THAT MAKES YOU GOOD AT THE POSITION YOU ARE APPLYING FOR?

4. WHAT WOULD YOU CONSIDER YOUR MOST IMPORTANT RESPONSIBILITY IN YOUR POSITION?

5. WHAT MAKES FOR A GOOD WORK EXPERIENCE?

6. HAVE YOU EVER HELD A JOB IN A SIMILAR POSITION IN ANOTHER COMPANY?

7. IF YES, SPECIFICALLY WHY DID YOU LEAVE?

8. IF YOU SHOULD BE SELECTED FOR AN INTERVIEW, YOU CAN HELP FACILITATE THE SCHEDULING BY PROVIDING US WITH THE BEST DAYS AND TIMES THAT YOU MIGHT BE AVAILABLE FOR AN INTERVIEW:

9. IF HIRED, WHAT IS YOUR AVAILABILITY? WHEN COULDYOU BEGIN WORK?

_______________________________________________________________________________________________________

Notice and Acknowledgement of Conditions of Employment

I, ___________________________, understand that as part of the pre-employment process, the

Masonic Charity Foundation of New Jersey may conduct a background investigation to

determine my suitability for the position for which I have applied.

I understand; as part of this process, I may undergo certain pre-employment medical

examinations and vaccinations and annual Mantoux testing. I understand that I may be

required to submit to a chest x-ray as the result of a positive Mantoux test. The test and X-ray

are done at a medical facility at no cost to me, or by a physician of my choice at my expense.

I understand; I will be required to submit to a drug screening through urinalysis; a negative

result on the drug screening is a condition of employment. I will be eliminated from employment

consideration if the results are positive.

I understand; I can refuse to undergo the drug testing. However, if I refuse or fail to provide a

urine sample for testing, I will be rejected for employment.

I understand; if I produce a positive test result for illegal drug use; those results will be held on

file and I will be precluded from applying for future employment for a period of at least one year.

I understand; if I produce a positive test result and I am a licensed medical professional or hold

a Commercial Driver’s License (CDL); the authority issuing said license may be made aware of

those results.

I understand; I will also be subject to whatever future testing is required by law for the position

I hold.

I further understand; I will be subject to random drug testing; refusal or failure to submit to

such testing will be grounds for dismissal. I also understand; a negative result for such testing

is a condition of continued employment; a positive test result may be grounds for dismissal.

I understand; any testing required as part of a reinstatement program will be at my expense.

A positive test at any time will result in immediate dismissal with no future opportunity for

reinstatement.

By my signature I acknowledge; I have read, understand and agree to comply with the

conditions of employment as stated above.

_________________________________________ _______________________________________

Applicant Signature/Date Signature of Parent/Guardian if a minor

902 JACKSONVILLE ROAD BURLINGTON, NEW JERSEY 08016-3896

609-239-3900 FAX 609-239-3905

Availability Questions

Do you have a vacation planned over the next 6 months?

YES NO

If yes, please provide dates: _____________________

Is there a day of the week that you cannot work?

Monday Tuesday Wednesday Thursday

Friday Saturday Sunday

(Only circle days you cannot work)

Is there a shift you cannot work?

1st (7a-3p) 2nd (3p-11p) 3rd (11p-7a)

(Only circle days you cannot work)

Masonic Charity policy:

All nursing team members must work every other weekend.

Do you have a weekend preference: ________________________________

By signing below I certify that the above information is true and

accurate to the best of my knowledge. I understand this document is

solely for discussion purposes and does not in any way guarantee time

off.

__________________________________________ ______________________________

Signature Date

REQUEST FOR REFERENCE

APPLICANT’S STATEMENT

I hereby grant permission to the Masonic Charity Foundation to verify the information I have provided on

the employment application; they may contact my previous and/or present employer for information

relative to my employment with them.

I hereby release from all liability and damages those individuals or companies who provide such

information.

_________________________________________ ________________________

Applicant’s Signature Date (Do not write below this line)

To: _____________________________________________

_____________________________________________

Re: _____________________________________________ ______________________________ Applicant’s name Social Security Number

POSITION APPLYING FOR: ____________________________________________

The Masonic Charity Foundation provides residential, skilled nursing and hospice services. The

applicant has applied for the position listed above. Your confidential verification of the

information below will be helpful in our consideration of this applicant. We would greatly

appreciate an early reply.

Thank you,

Human Resources Department

609-239-3805

EMPLOYER RESPONSE

Dates of employment: ___________________ to _____________________ Yes No

Position held: _______________________________ Yes No

Reason for leaving ________________________________________ Yes No

Is applicant eligible for rehire? Yes No If no, why not? _______________________________

_____________________________________________________________________________________________________

COMMENTS: _______________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________ _______________________________________________

Signature and Title Printed Name

______________________________________________ ___________________________

Phone number Date

902 JACKSONVILLE ROAD BURLINGTON, NEW JERSEY 08016-3896

609-239-3900 FAX 609-239-3905

EMPLOYMENT/SERVICE VERIFICATION FORM Human Resources

Telephone: 609-239-3898

Fax: 609-239-3905

Pursuant to the Health Care Professional Responsibility and Reporting enhancement Act (HCPRREA),

(P.L. 2005, c.83, effective October 30, 2005) which enables health-care entities (a) to exchange certain

information regarding health-care professionals (b) and in the interest of verifying such information, this

form seeks information regarding the health-care professional named below. Upon inquiry from a

health-care entity about a current or formerly employed health-care professional, health care entities

must provide the following information about that health-care professional (see N.J.S.A. §§ 26:2H-12.2c):

(1) job performance as it relates to patient care based upon job-performance evaluations;

(2) eligibility for re-employment at the health-care entity; (3) reason for separation for a formerly

employed health-care professional, and (4) copies of any notifications and supporting documentation sent

to the New Jersey Division of Consumer Affairs (DCA), medical practitioner review panel, and a

professional or occupational licensing board of the DCA within seven years preceding the date of this

inquiry (see N.J.S.A. §§ 26:2H-12.2a and 12.2b).

TO BE COMPLETED BY CANDIDATE (Please print)

Name of Candidate: ____________________________________________________________________________

Maiden Name/Other Names Used: _____________________________________________________________

Professional License or Certification Number: _________________________________________________

Position Applied For: ___________________________________________________________________________

Employer (Name & Address): ___________________________________________________________________

_____________________________________________________________ Phone: __________________________

Title(s) of Position(s) Held: _____________________________________________________________________

Dates Employed From: ____________________________________ To: _____________________________

Candidate Signature: _______________________________________ Date: ___________________________

TO BE COMPLETED BY FORMER/CURRENT HEALTH-CARE ENTITY/EMPLOYER

SECTION I

Name When Employed: __________________________________________________________________________

Title(s) of Position(s) Held: ______________________________________________________________________

Dates Employed From: ____________________________________ To: _____________________________

(a) The HCPRREA defines “health-care professionals” as health-care facilities licensed pursuant to N.J.S.A. §§ 26.2H-1 state and

county psychiatric hospitals and development centers, HMO’s, carriers offering managed-care plans, staffing registries and

home-care service agencies.

___________________________________________________________________________________________________________________________

902 JACKSONVILLE ROAD BURLINGTON, NEW JERSEY 08016-3896 609-239-3900 FAX 609-239-3905

(b) The HCPRREA defines “health-care professionals” as individuals licensed or authorized to practice a health-care profession

regulated by DCA or other professional and occupational licensing boards including but not limited to, physicians; podiatrists;

nurses; pharmacists; physical, occupational and respiratory therapists; psychologists, psychoanalysts; social workers; audiologists,

and speech-language pathologists; optometrist; ophthalmic dispensers and technicians; dentists; orthodontists and prosthetists;

marriage and family therapists; veterinarians, and chiropractors; and acupuncturists. Health-care professionals also include

home-health aides certified by the board of nursing and nurse aides and personal-care assistants certified by the Department of

Health and Senior Services.

REASON FOR SEPARATION OF EMPLOYMENT (please check all that apply)

Voluntary Reasons Involuntary Reasons

Voluntary Resignation Involuntary Lay-off

Voluntary Relocation Involuntary Discharge for Performance

Voluntary Lay-off Involuntary Discharge for Misconduct

Voluntary Resignation in Lieu of Discharge Voluntary Discharge for Attendance

Abandoned Position Other (provide description) _________________

Other (provide description) _________________

SECTION II

For all health-care professionals, please describe the health-care professional’s job performance as it

relates to patient care. Job performance relates to the suitability of the health-care professional for

re-employment at the health-care entity, the professional’s skills and abilities as they relate to suitability

for future employment at a health-care entity. Any job performance information provided should be

based on the professionals’ job-performance evaluation considering those evaluations signed by the

evaluator and shared with the health-care professional and the professional’s response to that evaluation

(see N.J.S.A. 26:2H-12.2c). Please check the appropriate box below regarding the health-care

professionals skills and abilities relating to patient care. (Attach additional pages as needed)

Please indicate date of the last/most recent performance evaluation: ________________________

Meets Standards Does not meet Standards

SECTION III

Is the health-care professional eligible for re-employment by the health-care entity? Yes or No

If “No, please provide an explanation as it relates to patient care (see Section II above)

SECTION IV

During the seven years preceding the date of this inquiry (see above), have you submitted any

notification to the New Jersey DCA, medical practitioner review panel, or occupational licensing board

about this health-care professional? Yes or No

If yes, please provide a copy of the notification and all supporting documentation as required by

N.J.S.A. 26:2H-12.2c

FORM COMPLETED BY:

___________________________________________ ___________________________________________

Print Name Signature

___________________________________________ _________________________

Title Date

___________________________________________ Phone Number