Application for Employment - CR-Fosston & CR-Extend Care

Today's Date*

Date

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Email*

example@example.com

Previous Names or Aliases

Current Address*

Street Address

Street Address Line 2

CityState

Zip Code

Previous Address (if less than a year ago)

Street Address

Street Address Line 2

CityState

Zip Code

Position(s) Applying for*

Pay Expected

Shift(s) Preferred

DaysAfternoons/EveningsOvernights

Shift Preferred

DaysAfternoon/EveningOvernight

Do you prefer full or part-time work?

Full-TimePart-Time

Have you ever applied for employment with us before?

YesNo

If yes, give the date

Date

Have you ever been employed with us before?

YesNo

If yes, give dates and position

Are you legally eligible for employment in the United States? Proof is required.

YesNo

Are you of legal age to work in the United Sates

YesNo

Are you a Registered Nurse, Licensed Practical Nurse, or a Certified Nursing Assistant? Enter Your License/Certification#

Professional or Civic organization membership (Exclude any which may disclose a protected class)

Do you have any special training or skills related to the position(s) applied for?

Please write a few sentences telling us why you have chosen to work in health care.

Did You Graduate from? (Select if "Yes")

Please list the name of the schools attended, their location, and the course of study.

Please upload your resume or complete the employment section below

Click Here to Upload File

Employer Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Type of Business

Supervisor

First NameLast Name

Dates of Employment

Job Title

Describe the work performed

Reason for leaving

Add New Employer

Yes

Employer Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Type of Business

Supervisor

First NameLast Name

Dates of Employment

Job Title

Describe the work performed

Reason for leaving

Add New Employer

Yes

Employer Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Type of Business

Supervisor

First NameLast Name

Dates of Employment

Job Title

Describe the work performed

Reason for leaving

Add New Employer

Yes

Employer Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Type of Business

Supervisor

First NameLast Name

Dates of Employment

Job Title

Describe the work performed

Reason for leaving

Please explain any intervals between employment dates of three (3) months or longer.

Name of Reference #1*

First NameLast Name

Please indicate if this is a personal or professional reference.*

PersonalProfessional

Relationship of Reference*

Phone Number*

Area CodePhone Number

Name of Reference #2

First NameLast Name

Please indicate if this is a personal or professional reference.

PersonalProfessional

Relationship of Reference

Phone Number

Area CodePhone Number

Add another reference

Yes

Name of Reference #3

First NameLast Name

Please indicate if this is a personal or professional reference.

PersonalProfessional

Relationship of Reference

Phone Number

Area CodePhone Number

PLEASE READ CAREFULLY AND SIGN BELOW

I certify that to the best of my knowledge, the facts contained on my application are true and correct, without substantial omissions. I understand that if I am chosen for employment, any false information on this application may result in immediate discharge. I further understand this application is not and is not intended to a contract of employment, nor does this application obligate Cornerstone Residence in any way, if they decide to employ me. I understand and agree that any employment is at-will and can be terminated by either party with or without notice, at any time, for any reason or no reason.

Cornerstone Residence is an Equal Opportunity Employer. We consider Applicants of all positions without regard to race, religion, creed, gender, national origin, age, marital or veteran status, sexual orientation, status with regard to public assistance, or any other legally protected status.

I agree to submit to a Mantoux test, or chest x-ray, if a previous Mantoux test has been positive, in compliance with the State of Minnesota Department of Health Regulation 4655.3000, subparts 1-4.

I further understand, that if I am employed by Cornerstone Residence, and upon completion of that employer/employee relationship, my signature below gives Cornerstone Residence the permission to release information related to my employment, including, but not limited to: dates of employment and positions held.

Today's Date*

Date

Signature*

Application for Employment - Cornerstone Residence of Fosston

Education

Employment Experience

References