Employment Application

Employment Desired

Will accept employment of:

Are you a United States Citizen?

Do you have a Work Permit?

Do you have a valid Driver's License?

Were you previously employed by us?

List any friends or relatives working for us

Emergency Contacts

Education / Training

High School


Other Training

Professional Licenses and/or Certifications

Nursing Assistant

Are you currently on the Minnesota Registry?

Additional Professional Licenses and/or Certifications

Military Record

Are you currently active in the Military?

Employment History

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

May we contact for a reference?

Company #2

May we contact for a reference?

Company #3

May we contact for a reference?


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.