Full Name

Date

Present Address

Phone

Email Address

Permanent Address (if different than present address)

If you cannot be reached at the above phone, where can we reach you?

Employment Desired Employment Desired

Work Desired

Wage

Shift

Work Desired

Wage

Shift

Work Desired

Wage

Shift

Where did you learn about this position?

Date Available

Will accept employment of: Will accept employment of: Full Time Part Time Temporary

What hours are you available for work?

Are you a United States Citizen? Are you a United States Citizen? Yes No

Do you have a Work Permit? Do you have a Work Permit? Yes No

Do you have a valid Driver's License? Do you have a valid Driver's License? Yes No

Were you previously employed by us? Were you previously employed by us? Yes No

When were you employed with us?

Reason for leaving

List any friends or relatives working for us List any friends or relatives working for us

Name

Relationship

Name

Relationship

Name

Relationship

Emergency Contacts Emergency Contacts

Name

Relationship

Phone

Name

Relationship

Phone

Education / Training Education / Training

High School High School

Name/Address of School

Courses Taken

Graduation Date

Degree/Certificate

College College

Name/Address of School

Courses Taken

Graduation Date

Degree/Certificate

Other Training Other Training

Name/Address of School

Courses Taken

Graduation Date

Degree/Certificate

Other Classes/Training

Extracurricular Activities While in School

Area of Specialization or Major Interest

Professional Organization Memberships, Honors Received, Volunteer or Community Service, or Other Qualifications You Have Which You Feel Are Related to the Position Which You Are Applying For

Professional Licenses and/or Certifications Professional Licenses and/or Certifications

RN/LPN's

State

Number

RN/LPN's

State

Number

RN/LPN

State

Number

Nursing Assistant Nursing Assistant

Are you currently on the Minnesota Registry? Are you currently on the Minnesota Registry? Yes No Pending

Social Security Number

Other states where registered

Additional Professional Licenses and/or Certifications Additional Professional Licenses and/or Certifications

Type

State Issued

Date Issued

Number

Verification

Type

State Issued

Date Issued

Number

Verification

Type

State Issued

Date Issued

Number

Verification

Military Record Military Record

Military Branch

Date Entered

Separation Date(s)

MOS

Are you currently active in the Military? Are you currently active in the Military? Yes No

Rank at Discharge

Specialized Training

List any Service Awards for Commendations

Employment History Employment History

List current (or most recent) Employer first and all others in reverse chronological order. List current (or most recent) Employer first and all others in reverse chronological order.

Company Name

Dates Employed

Address

Phone

Position Title

Supervisor

Job Description and Responsibilities

May we contact for a reference? May we contact for a reference? Yes No

Company #2 Company #2

Company Name

Dates Employed

Address

Phone

Position Title

Supervisor

May we contact for a reference? May we contact for a reference? Yes No

Job Description and Responsibilities

Company #3 Company #3

Company Name

Dates Employed

Address

Phone

Position Title

Supervisor

Job Description and Responsibilities

May we contact for a reference? May we contact for a reference? Yes No

References References

Name and Occupation

Address

Phone

Name and Occupation

Address

Phone

Name and Occupation

Address

Phone

In a few sentences or a short paragraph, please tell us why you would like to work for this organization

Employment Understanding Employment Understanding

This organization does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, veteran status, or on the basis of age or physical or mental disability unrelated to the ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination. I voluntarily give this organization the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take a physical examination and such future physical examinations as may be required by this organization at such times and places as the organization shall designate. I understand that an offer of employment may be contingent on the ability to perform the physical strengths which relates to the essential duties I would be required to perform. I understand that my employment is at-will and that either party is free to terminate the employment relationship at any time without cause. I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge and agree that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date. If employed, I will be required to complete an Employment Verification Form (I-9) and within three days show satisfactory evidence of identity and eligibility for employment. I understand that this organization operates seven days a week, 24-hours-per-day and the primary concern in scheduling staff is consistent, quality care for residents. Meeting this commitment may mean I will be asked to work at times and in areas not usual to my schedule. I agree to such scheduling. This organization does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, veteran status, or on the basis of age or physical or mental disability unrelated to the ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination. I voluntarily give this organization the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take a physical examination and such future physical examinations as may be required by this organization at such times and places as the organization shall designate. I understand that an offer of employment may be contingent on the ability to perform the physical strengths which relates to the essential duties I would be required to perform. I understand that my employment is at-will and that either party is free to terminate the employment relationship at any time without cause. I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge and agree that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date. If employed, I will be required to complete an Employment Verification Form (I-9) and within three days show satisfactory evidence of identity and eligibility for employment. I understand that this organization operates seven days a week, 24-hours-per-day and the primary concern in scheduling staff is consistent, quality care for residents. Meeting this commitment may mean I will be asked to work at times and in areas not usual to my schedule. I agree to such scheduling.

Applicant's Signature

Date