EMPLOYMENT / JOB APPLICATION

EMPLOYMENT / JOB APPLICATION
Facility *
PERSONAL INFORMATION
First Name *
Middle Name *
Last Name *
Date *

Month Day Year
Date
Street Address *
Apt/Suite
City *
State *
Zip Code *
Email *
example@example.com
Phone *
Date Available *

Month Day Year
Date
Desired Pay *
Desired Pay - Hourly or Salary *

Hourly Salary
Position Applied For *
Employment Desired *

Full-Time Part-Time On Call
EMPLOYMENT ELIGIBILITY
Are you legally eligible to work in the U.S? *

Yes No*
Have you ever worked for this employer? *

Yes No
*If Yes, Write The Start Date

Month Day Year
Date
*If Yes, Write The End Date

Month Day Year
Date
EDUCATION
High School
High School *
City / State *
From *
To *
Graduate? *

Yes No
Diploma *
College
College
City / State
From
To
Graduate?

Yes No
Degree
Other
Other
City / State
From
To
Degree / Certification
PREVIOUS EMPLOYMENT
EMPLOYER 1
EMPLOYER 1
Company / Individual
E-MAIL
example@example.com
PHONE
Street Address
Apt/Suite
City
State
Zip Code
STARTING PAY
STARTING PAY

HOURLY SALARY
ENDING PAY
ENDING PAY

HOURLY SALARY
JOB TITLE
RESPONSIBILITIES
FROM

Month Day Year
Date
TO

Month Day Year
Date
REASON FOR LEAVING
EMPLOYER 2
EMPLOYER 2
Company / Individual
E-MAIL
example@example.com
PHONE
Street Address
Apt/Suite
City
State
Zip Code
STARTING PAY
STARTING PAY

HOURLY SALARY
ENDING PAY
ENDING PAY

HOURLY SALARY
JOB TITLE
RESPONSIBILITIES
FROM

Month Day Year
Date
TO

Month Day Year
Date
REASON FOR LEAVING
REFERENCES

(PROFESSIONAL ONLY)
FIRST NAME
LAST NAME
RELATIONSHIP
COMPANY
TITLE
E-MAIL
example@example.com
PHONE
FIRST NAME
LAST NAME
RELATIONSHIP
COMPANY
TITLE
E-MAIL
example@example.com
PHONE
Voluntary Disclosure
We are an Equal Employment Opportunity Employer. This company considers applicants for all positions without regard to race, color, creed, religion, national origin, veteran status, gender, age disability, marital status, sexual orientation, or status with regard for public assistance. Requests for accommodations will be considered and honored based on reasonableness of request.

The following information is necessary for this company to evaluate its hiring practices and to track its progress and effectiveness in complying with its Affirmative Action Plan and equal employment policies. The information is voluntary and will be kept confidential insofar as possible. Information provided will not be negatively considered in any part of the selection process.
Ethnic Background

Hispanic or Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. American Indian or Alaska Native (Not Hispanic or Latino) -A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. Black or African American (Not Hispanic or Latino) -A person having origins in any of the black racial groups of Africa. Asian (Not Hispanic or Latino) - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. White (Not Hispanic or Latino) - A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino) - A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Two or More Races (Not Hispanic or Latino) - All persons who identify with more than one of the above five races. I choose not to provide race information.
VETERANS INVITATION TO SELF-IDENTIFY
Regulations issued by the U.S. Department of Labor with respect to Vietnam Era veterans and other protected veterans require that federal contractors provide an opportunity for self-identification to candidates seeking employment. Such self-identification is submitted on a voluntary and confidential basis for use only in accordance with regulations, and without subjecting the individual to adverse treatment.

The 4 classifications of protected veterans are listed below:

Disabled Veteran is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability.

Recently Separated Veteran means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.

Active Duty Wartime or Campaign Badge Veteran means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

Armed Forces Service Medal Veteran means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

If you believe you belong to any of the categories of protected veterans, listed above, please indicate by checking the appropriate box below. As a Government contractor subject to VEVRAA, we request this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA.
Veterans Invitation to Self-Identify *

I identify as one or more of the classifications of protected veteran listed above I am not a protected veteran I don't wish to answer
Additional Questions
Income expectations* *
Date of availability* *

Month Day Year
Date
Are you 16 years or older?* *
CNA Certification Number / Nursing License Number
Applicant Statement
“I have not been found guilty in a court of law of abusing, neglecting, or mistreating individuals.”

“I authorize the investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.”

“I understand, if I have a disability which would require reasonable accommodation in order for me to participate in any portion of the application, interview, testing process and/or ongoing employment, that I have the right to submit a written request of such accommodation to this employer.”

“I certify that the facts contained in this application are true and complete to the best of my knowledge and understanding. That, if employed, falsified statements on this application shall be grounds for dismissal.”

“I understand that employment by Monarch Healthcare Management is not contracted but at-will employment.”

“I understand that Monarch Healthcare Management is committed to a policy of equal treatment and opportunity without regard to race, color, creed, religion, national origin, sex, age, disability, marital status, sexual orientation, gender identify, veterans status, status with regard to public assistance, union or non-union affiliation.”

“I understand that Minnesota and Wisconsin Statutes requires the Department of Human Services to conduct background studies on individuals providing direct contact services to residents in nursing homes, and if I am given a conditional job offer for employment at this facility, I will be required to provide sufficient information to ensure an accurate background study.”

By submitting this application, I affirm that I have read and agree to all of the disclosures and conditions included in the on-line application.
Applicant Statement *

I agree to the above.
Signature* *
Type Full Name (ex. John Albert Doe)
Date *

Month Day Year
Date
Personal Information
Shift Preferences (day, evening, night) List any that apply.
Employment Preference (check all that apply)* *

Regularly Scheduled Full Time Regularly Scheduled Part Time On Call Intermittent Student Other
Available* *

Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Hours Available* *
Keyword
DISCLAIMER
Applicant understands that this is an Equal Opportunity Employer and committed to excellence through diversity. In order to ensure this application is acceptable, please print or type with the application being fully completed in order for it to be considered.

Please complete each section EVEN IF you decide to attach a resume.

I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this application leads to my eventual employment, I understand that any false or misleading information in my application or interview may result in my employment being terminated.
SIGNATURE *

Clear
DATE *

Month Day Year
Date
PRINT NAME *
Should be Empty:

EMPLOYMENT / JOB APPLICATION

PERSONAL INFORMATION

EMPLOYMENT ELIGIBILITY

EDUCATION

High School

College

Other

PREVIOUS EMPLOYMENT

EMPLOYER 1

EMPLOYER 2

REFERENCES

Voluntary Disclosure

VETERANS INVITATION TO SELF-IDENTIFY

Additional Questions

Applicant Statement

Personal Information

DISCLAIMER