Application for Employment


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We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the organization.

We are an Equal Opportunity Employer.

PERSONAL INFORMATION:
Name (First, Middle, Last):
Street:
City:
State:
Zip:
Daytime Phone:
Evening Phone:
Email:
Referral Source:
(Newspaper, Job Service, etc.)
Social Security #:

EMPLOYMENT INFORMATION:
Position Desired:   Full Time   Part Time   Flex Status
Date you can start:

Were you previously employed by Lutheran Sunset Home? Yes No
Are you legally eligible for employment in the United States? Yes No
Are you 16 years of age or older? Yes No
Have you ever been convicted of a crime, excluding minor traffic violations? Yes No
(A record will not necessarily bar you from consideration for employment. Age and time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into consideration.)
Have you ever been employed as a CNA? Yes No
If yes, list all states you worked as a CNA:  

CERTIFICATION INFORMATION:
Current CNA Certificate #:  
State where issued:         Expiration Date:  
CNA's: If still in class, please note test site & test date here:  
Professionals, indicate License or Certificate Number: (RN, LPN, LSW, LRD, etc.)
Type:     State(s):       Number:       Expiration Date:  

CNA's: Have you ever had a nurse aide registry listing or certification marked for abuse? Yes No
RNís and LPNís: Have you ever been investigated by a Board of Nursing? Yes No

EDUCATION:
Do you have a high school degree or equivalency?: Yes No

Name & Address of last school attended:
If you have completed education beyond high school graduation or equivalency, please state:
Degree (type):     Major Area of Study:  
Other education relevant to position:

EMPLOYMENT HISTORY:
Present or Most Recent Employment Information
Name of Employer:
Address:
Phone:
Immediate Supervisor's Name and Title:
Position Held:
Duties Performed:
Dates of Employment:From to
Salary/Wage:
Reason for Leaving:
May We Contact? Yes   No
Second Previous Employer
Name of Employer:
Address:
Phone:
Immediate Supervisor's Name and Title:
Position Held:
Duties Performed:
Dates of Employment:From to
Salary/Wage:
Reason for Leaving:
May We Contact? Yes   No
Third Previous Employer
Name of Employer:
Address:
Phone:
Immediate Supervisor's Name and Title:
Position Held:
Duties Performed:
Dates of Employment:From to
Salary/Wage:
Reason for Leaving:
May We Contact? Yes   No

REFERENCES:
Please give the names of three individuals whom you have known for at least one (1) year. NO relatives please.
NameOccupation/TitleTelephoneYears Known

APPLICANT'S CERTIFICATION:
"I certify that answers given herein are true, authorize their investigation, and agree that any misleading or false statements would render this application void and could be sufficient cause for immediate dismissal in the event of employment."

Name/Signature:    Date:   5/23/2018

Verification Code:*
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No spaces are necessary.

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Lutheran Sunset Home • 333 Eastern Ave. • Grafton, ND 58237 • Phone: (701) 352-1901 • Email:

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