Employment Application 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 Start Wage End Wage 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 Start Wage End Wage 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 Start Wage End Wage 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 Submit
