EMPLOYMENT APPLICATION FORM SPIRIT 530 WWHAPPFORM

User Manual: SPIRIT 530

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Christ Centered Elder Care
RCFE LIC 115001617
1440 Fairview St; Orland, CA 95963
(530) 865-5299 FAX (530) 865-9333
1
EMPLOYMENT APPLICATION FORM
I. PERSONAL
Last Name: First:
Middle:
Address:
Telephone: Mobile Telephone:
Are you 18 years of age or older?
Yes
No SS# (voluntary for ID only):
Date of last physical examination: / /
Unknown
Date of last TB Test: / /
Unknown
Have you ever been employed under a different name? If yes, please list all names used.
Yes
No
Do you possess a valid
California driver’s license?
Yes
No
CDL Number: Has your driver’s license ever been suspended or revoked?
If yes, please explain (you may attach a separate page).
Yes
No
NEAREST LIVING RELATIVE/ OTHER CLOSE PERSONAL CONTACT
Name:
Address: Telephone:
Relationship:
II. POSITION(S) SEEKING (check all that apply)
Full Time
Part
Time
Internship
Other
Resident Care
Food Services/Facilities
Housekeeper
Administrative Support
Other____________________
Wage Request: $_____________
per hour
Shifts (indicate availabilities):
Days
PM’s
Nights
Weekends
Available Starting Date: / /
III. PREVIOUS EMPLOYMENT
(List most recent experience first, and include at least 3 years of work history. You may attach extra pages.)
Dates May We
Contact
Name and Address of
Employer Telephone
Number Job Title and
Type of Work Reason for Leaving From To
Revised: 03-21-06
Christ Centered Elder Care
RCFE LIC 115001617
1440 Fairview St; Orland, CA 95963
(530) 865-5299 FAX (530) 865-9333
2
IV. EDUCATION
List all Earned Degrees/Certificates and Certificate Numbers:
Check all that apply:
No High School Diploma
High School Diploma/Certificate
Some College/No Degree
Associates Degree Earned
Bachelors Degree Earned
Masters Degree or Above
LVN or RN (Circle One)
Other ____________________
Currently enrolled in high school completion course? If yes, give expected
completion date.
Yes
No
Name University, College, or
Business School and Address Major/Subject Number.
of Years
Attended
Number of
Units
Completed
Diploma/Degre
e/Certificate Date
Completed
EMPLOYMENT-RELATED EDUCATION COURSES
Course Title Name of School or Organization and
Address
Number of
Units
Completed
Date
Completed Currently
Enrolled
V. REFERENCES
(Include former employment and personal references)
Name Address Telephone
Number Relationship to You (Friend,
Employer, etc.)
Revised: 03-21-06
Christ Centered Elder Care
RCFE LIC 115001617
1440 Fairview St; Orland, CA 95963
(530) 865-5299 FAX (530) 865-9333
3
VI. TESTIMONY OF FAITH
WestHaven Assisted Living is a Christ-centered, faith-based ministry to the elderly. All applicants are invited to share their
testimony of faith as part of their application. Please include specific details regarding your view of the Bible, participation
in a local church, doctrinal beliefs, etc. in the space below.
Revised: 03-21-06
Christ Centered Elder Care
RCFE LIC 115001617
1440 Fairview St; Orland, CA 95963
(530) 865-5299 FAX (530) 865-9333
4
VII. APPLICANT RELEASE OF INFORMATION
WestHaven Assisted Living does not discriminate based on sex, race, color, or natural origin. Pursuant to Federal and
State laws, WestHaven identifies religion as a bona-fide occupational qualification for all staff members. These
requirements are outlined in the WestHaven Statement of Faith, Employment Covenant, etc. As a non-profit religious
organization WestHaven does not participate in the state unemployment or disability insurance programs.
In the event I am offered employment I understand that prior to start of work I shall be required to furnish evidence of
Department of Justice (DOJ) criminal background clearance, a valid Red Cross approved Basic First Aid Card, a signed
Pastoral Reference Form, and a release from a physician of fitness of duty as recorded on form LIC503. I understand that
these certifications are pre-requisites for employment and I am not paid to attend any required course or receive any
reimbursements of fees paid by me to obtain it unless noted in an Offer of Employment letter. I may also be required to
provide evidence of motor vehicle records (DMV Printout) and automobile insurance as a condition of employment under
the same terms.
I hereby certify under penalty of perjury that the above statements are true and correct. I give my permission for any
necessary verification. I further understand that any deliberate, factual error or a misrepresentation may be grounds for
termination.
Applicant Signature:________________________________________________
Date:____________________________
WestHaven Mission Statement
Christians need never retire from kingdom living.
To bring glory to God by providing meaningful participation in the ministry of the Gospel of
Jesus Christ to elderly members of our community through the operation of senior residential
facilities.
WestHaven Vision Statement Excerpts
To provide assistance with activities of daily living to seniors, especially Christian widows,
through the development and operation of residential care facilities.
To enrich the lives of seniors in our community through ministry which nurtures physical,
social, and spiritual life.
To strive, by God’s grace, to expand the ministry to serve the greatest number of seniors in
facilities which are operated according to the highest ethics of the community of Christ.
Revised: 03-21-06
Christ Centered Elder Care
RCFE LIC 115001617
1440 Fairview St; Orland, CA 95963
(530) 865-5299 FAX (530) 865-9333
5
Statement of Faith
We believe:
that the Bible, in the original autographs, is the only inerrant and inspired Word of God and is,
therefore, our final authority.
in the eternally existing, triune God: Father, Son, and Holy Spirit.
in the deity of Jesus Christ, His virgin birth, His sinless life on earth, His miracles, His
atonement for the sins of men through His suffering and death on the cross, His bodily
resurrection, and His ascension to the right hand of the Father where He now acts as
Mediator and Advocate for the purchased saints known as the Church.
in the personal return of our Lord Jesus Christ in power and glory to reign in righteousness
over the Kingdom of God. We believe in the bodily resurrection of both the saved and the
lost; the saved to the resurrection of life and the lost to the resurrection of damnation.
that the fall of mankind from his state of innocence, an historical fact recorded in the book of
Genesis has rendered all of mankind guilty, sinful, and spiritually dead. Regeneration by the
Holy Spirit is the sole remedy for this fallen condition and is essential for the salvation of
fallen and sinful men.
that the good news of the Gospel is that God Himself has provided a righteousness in His
Son, the Lord Jesus Christ, that is received by faith alone, so that our salvation is neither
wholly or in part dependant upon our good works.
in the present ministry of the Holy Spirit who indwells all true believers and enables them to
believe the Gospel, to obey God’s commands from the heart, and to persevere in faith.
in the spiritual unity of all the saints of God who have been granted faith and eternal life. We
further believe in the necessity of good works as evidence of genuine faith.
that eternal life in heaven with God is reserved for believers and that eternal wrath in hell is
reserved for unbelievers.
Revised: 03-21-06

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