BHR JOB APPLICATION

Personal Information

ALL FIELDS ARE REQUIRED. IF NOT APPLICABLE, TYPE "N/A" IN THE BOX. THANK YOU.

Last name

First name

Middle name

Today's Date(mm/dd/yyyy)

Email Address

Street Address

Home Telephone(xxx-xxx-xxxx)

City State Zip Code

Business Telephone(xxx-xxx-xxxx)

Have you ever applied for employment with us?
Yes No If yes, Month and Year Location

Social Security # (xxx-xx-xxxx)

Position Desired

Branch/Job Site

Apart from absence for religious observance, are you available for full-time work hours?
Yes No If no, what hours can you work?

Are you legally eligible for employment in the United States? Yes No	When will you be available to begin work?
Do you have any disabilities that may require BHR to provide special accommodations?Yes No	Salary Desired?
Have you ever been terminated from a job? Yes No	Please explain:
Have you ever been convicted of a felony? Yes No	Please explain:
Are you applying for a Clinical position? Yes No	If yes, what is your NPI # Medicare #:

EDUCATION
Name of school		Type
Major		Degree Earned
Years completed

EMPLOYMENT HISTORY
Please give accurate, complete full-time and part-time employment record.Start with your present or most recent employer.

Company 1
Company Name		Telephone(xxx-xxx-xxxx)
Address		Employed-(mon. & yr. eg. Nov. 1972 => 1172) From To
Name of Supervisor		Pay per Start Last
State Job Title and Describe your work		Reason for Leaving
Starting salary Ending Salary

Company 2
Company Name		Telephone(xxx-xxx-xxxx)
Address		Employed-(mon. & yr. eg. Nov. 1972 => 1172) From To
Name of Supervisor		Pay per Start Last
State Job Title and Describe your work		Reason for Leaving
Starting salary Ending Salary

Company 3
Company Name		Telephone(xxx-xxx-xxxx)
Address		Employed-(mon. & yr. eg. Nov. 1972 => 1172) From To
Name of Supervisor		Pay per Start Last
State Job Title and Describe your work		Reason for Leaving
Starting salary Ending Salary

Company 4
Company Name		Telephone(xxx-xxx-xxxx)
Address		Employed-(mon. & yr. eg. Nov. 1972 => 1172) From To
Name of Supervisor		Pay per Start Last
State Job Title and Describe your work		Reason for Leaving
Starting salary Ending Salary


We may contact the employers	DO NOT CONTACT
listed above, unless you indicate those you do not want us to contact.	Employer Number(s) Reason

Licenses, certifications, or special training

Describe any licenses, certifications, or special training you have which is relevant to the position for which you are applying

I understand and acknowledge the following:

1.If I am offered employment, I will, as a condition of employment, be required to submit proof of my identityand legal right to work in the United States.

2.I understand that, if I am employed, any false statement, misrepresentation or omission of facts on thisapplication, on any supporting documents, or provided orally, regardless of when discovered to be false, willresult in my immediate dismissal.

3.I understandand agree that, if I am offered a position, it will be offered on condition that my employment shall be at will and for no definite period, and that my employment may be terminated, at any time, with orwithout cause and with or without prior notice.

4.I understand that no supervisor or manager may alter or amend the above conditions except in writing, signed by a Company Officer.

5.In exchange for the Company's considering my application for employment, I authorize investigation of all statements contained in this application and any supporting documents. I authorize BHR to conduct a complete criminal background check. I authorize BHR, Corp. to secure information about my experience from former employers, educational institutions, government agencies, or any references I have provided, and for those parties to provide such information concerning the subjects covered herein, and I hereby release all parties from any liability arising from such investigations.

6.In exchange for the Company's considering my application for employment, I hereby authorize my former employer to release to BHR Corp, any personnel information and records, favorable or otherwise, which my employer has kept regarding my employment, including my work performance.I understand that BHR, Corp. may retain photocopies of my records for its files, whether I am offered employment or not.I herby release all parties, including my former employer and BHR, Corp. from any liability arising from the release, review and retention of any records pertaining to me.

Signature (Type name to sign the form)

Date(mm/dd/yyyy)

List 3 References (Supervisor and Managers only)

Reference #1	Supervisor’s Name
	Company Name
	Telephone Number(xxx-xxx-xxxx)
	Dates of Employment

Reference #2	Supervisor’s Name
	Company Name
	Telephone Number(xxx-xxx-xxxx)
	Dates of Employment

Reference #3	Supervisor’s Name
	Company Name
	Telephone Number(xxx-xxx-xxxx)
	Dates of Employment

Reference #4	Supervisor’s Name
	Company Name
	Telephone Number(xxx-xxx-xxxx)
	Dates of Employment

ALL FIELDS ARE REQUIRED. IF NOT APPLICABLE, TYPE "N/A" IN THE BOX. THANK YOU.