Elm Crest Manor Providing Quality Skilled Care
Since 1969 New (701) 843-7526 Fax # (701) 843-8376
EMPLOYMENT APPLICATION
Date: ____________
NAME:
______________________________________________________
ADDRESS:
__________________________________________________
TELEPHONE:
_________________ SOCIAL SECURITY #____________
ARE YOU 16 YEARS OF AGE OR OLDER? _______YES
_______NO
POSITION
APPLIED FOR: ____________________________________________________________
SHIFTS
YOU CAN WORK: _______DAY _______EVENIING _______NIGHT
_______ANY
HOURS
DESIRED: _______FULL TIME _______PART TIME
ARE
YOU AVAILABLE TO WORK WEEKENDS: _______YES _______NO
HAVE
YOU EVER WORKED FOR ELM CREST BEFORE:
_______YES _______NO
WHEN:
________________________ SUPERVISOR: ____________________________________
REASON
FOR LEAVING: ____________________________________________________________
HAVE
YOU BEEN CONVICTED OF A FELONY OR HAVE FELONY CHARGES PENDING?
________YES _________NO
HAVE
YOU HAD CONVICTIONS FOR MISTREATMENT, NEGLECT OR ABUSE OF RESIDENTS, OR
MISAPPROPRIATIONS OF PROPERTY: ________YES ________NO
IF
YOU ANSWER IS YES PLEASE EXPLAIN:
REFERED
BY: _________________________________________________________________________
EDUCATION:
HIGHEST
GRADE COMPLETED 1 2 3 4 5 6 7 8 9 10 11 12 (PLEASE CIRCLE)
COLLEGE 1 2 3 4
OTHER
EDUCATION: __________________________________________________________________
CNA
Certified _______ YES _______ NO License # ___________________
LPN
License# __________________
RN License # _______________________
EMPLOYMENT
HISTORY/PERSONAL REFERENCE (IF NO PRIOR EMPLOYEMENT)
COMPANY
NAME DATES
EMPLOYED
_____________________________________________ FROM ____________________ TO:
_________________
ADDRESS PHONE:
_____________________________________________ ________________________________________________
POSITION/TITLE IMMEDIATE
SUPERVISOR NAME AND TITLE
_____________________________________________ ________________________________________________
JOB
DESCRIPTION & RESPONSIBILITIES: _________________________________________________________
REASON
FOR LEAVING:
_________________________________________________________________________
MAY
WE CONTACT FOR REFERENCE:
_______YES _______NO
COMPANY
NAME DATES
EMPLOYED
_____________________________________________ FROM ____________________ TO:
_________________
ADDRESS PHONE:
_____________________________________________ ________________________________________________
POSITION/TITLE IMMEDIATE
SUPERVISOR NAME AND TITLE
_____________________________________________ ________________________________________________
JOB
DESCRIPTION & RESPONSIBILITIES:__________________________________________________________
REASON
FOR LEAVING: _________________________________________________________________________
MAY
WE CONTACT FOR REFERENCE:
_______YES _______NO
COMPANY
NAME DATES
EMPLOYED
_____________________________________________ FROM ____________________ TO:
_________________
ADDRESS PHONE:
_____________________________________________ ________________________________________________
POSITION/TITLE IMMEDIATE
SUPERVISOR NAME AND TITLE
_____________________________________________ ________________________________________________
JOB
DESCRIPTION & RESPONSIBILITIES:
_________________________________________________________
REASON
FOR LEAVING:
_________________________________________________________________________
MAY
WE CONTACT FOR REFERENCE:
_______YES _______NO
OFFICE USE ONLY
REFERENCE CHECKED:________________________________________________________________________
DATE:____________
COMMENTS:_________________________________________________________________
________________________________________________________________________________________________
This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, or on the basis of age or physical or mental disability. No question on this application is intended to secure information to be used for such discrimination.
I voluntarily give this institution 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 the
employment physical examination, after a conditional offer of employment and
such future physical examinations as may be required by this institution at
such times and places as the institution shall designate.
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 also understand that my
employment may be terminated for any statement-statement or omission of fact
appearing on the application form.
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.
_______________ __________________________________________
Date Applicant’s
Signature
DO NOT ANSWER QUESTIONS IN
THIS AREA – TO BE COMPLETED AFTER EMPLOYED.
Date of Birth _______________ Marital Status ________________________
Notify in case of Emergency: (name, address, telephone)
ABUSE REGISTRY CHECKED:
DATE: ______________________
COMMENTS: ___________________________________________________________
SIGNATURE: ___________________________________________________________