Application for Employment

Please Read the Following Statement Before Completing this Employment Application

Cornerstone Nursing & Rehab Center 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.

All offers of employment shall be considered conditional based upon the following conditions: Accurate completion of this and all employment forms; negative results of tuberculin test; the ability to access information on the status of RN, LPN or CNA licensure or certification (if applicable), driving record; and legally eligible for employment in the United States of America.

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

Please select which facility you are interested in working at.*

Position(s) Applying for*

Pay Expected

Shift(s) Preferred

DaysAfternoons/EveningsOvernights

Shift Preferred

DaysAfternoons/EveningsNights

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#

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

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

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.

You may 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.

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 Nursing & Rehab Center 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 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, and upon completion of that employer/employee relationship, my signature below gives Cornerstone Nursing & Rehab Center the permission to release information related to my employment, including, but not limited to: dates of employment, and positions held. I hereby release Cornerstone, its affiliates, and representatives from any liability that may result in the release of the above-stated information.

If you have questions please contact HR at 218-435-7369.

Today's Date*

Date

Signature*

Education

Employment Experience