Employment Application

Personal Information

Name: Date:
Present Address:
Phone: Email:
Permanent Address:(if different than present address)
If you cannot be reached at the above phone, where can we reach you?

Employment Desired

Work Desired


Wage


Shift


Where did you learn about this position? Date Available:
Will accept Employment of: Full TimePart TimeTemporary
What hours are you available for work? or
Are you a United States Citizen? YesNo
If not, do you have a Work Permit? YesNo
Do you have a valid Driver’s License? YesNo
Were you previously employed by us? YesNo
If yes, when? Reason for leaving:

List any Friends or Relatives working for us

Name


Relationship


Person to contact in case of an accident or emergency:
Person to contact in case of an accident or emergency:

Education / Training

School
High School
College
Other Training

Name / Address of School


Courses Taken


Graduate? 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

RN/LPN’s


State


Number


    Nursing Assistant:

Are you currently on the Minnesota Registry? YesNoPending
Social Security Number: (For Registry Confirmation)
Other states where registered:

Additional Professional Licenses and/or Certifications

Type


State Issued


Date Issued


Number


Verification


Military Record

Military Branch

Date Entered

Separation Date(s)

MOS

Are you currently active in the Military? YesNo   Rank at Discharge:
Specialized Training:

List any Service Awards or Commendations:

Employment History

List current (or most recent) Employer first and all others in reverse chronological order.
Company Name:    Dates Employed:
Address:
Phone:    Start Wage:    End Wage:
Position Title:    Supervisor:
Job Description and Responsibilities:

May we contact for a reference? YesNo
Company Name:    Dates Employed:
Address:
Phone:    Start Wage:    End Wage:
Position Title:    Supervisor:
Job Description and Responsibilities:

May we contact for a reference? YesNo
Company Name:    Dates Employed:
Address:
Phone:    Start Wage:    End Wage:
Position Title:    Supervisor:
Job Description and Responsibilities:

May we contact for a reference? YesNo
Company Name:    Dates Employed:
Address:
Phone:    Start Wage:    End Wage:
Position Title:    Supervisor:
Job Description and Responsibilities:

May we contact for a reference? YesNo


References List Three References Who Are Not Relatives Or Former Employers

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 (Please Read and Sign.)

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 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: