• Hiawatha Care Center Application for Employment

  • Date of Application*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Date Of Birth*
     - -
    4 digit year, 2 digit month, 2 digit day
  • Are you at least 18 years of age?*
  • Are you at least 16 years of age?*
  • If less than 16 do you have a work permit?*
  • Have you ever been employed here before?*
  • If yes, give a date.*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Are you employed now?*
  • May we contact your current employer?*
  • Can you, if hired, submit verification of your legal right to work in U.S.?

  • If hired, you will be required to submit documents sufficient to establish employment authorization & identify compliance with the immigration reform and control act of 1986.  While you need not provide this proof of citizenship or immigration status at the time you are interviewed, please be prepared to assure us that you can do so immediately upon being hired.

  • On what date would you be available for work?*
     - -
    4 digit year, 2 digit month, 2 digit day
  • Work Schedule Availability*
  • If temporary, what days?
  • If temporary, what hours?
  • Are you on a lay off and subject to recall?*
  • If you received the COVID-19 vaccine, you will be required to provide proof of the vaccine upon hire, are you able to meet this requirement? (COVID-19 vaccines are not a requirement of employment)*
  • Have you ever been convicted of a crime in this state of any other?*
  • Do you have a record of founded child or dependent adult abuse?*
  • Date*
     - -
    4 digit year, 2 digit month, 2 digit day
  • Education Level
    Rows

  • Employment Experience

    Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race color, religion, gender, national origin, disabilities or other protected status
  • Format: (000) 000-0000.
  • Employer Start Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Employer End Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Employer Start Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Employer End Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Employer Start Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Employer End Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • New Employee or Change of Employee Information Worksheet

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Pursuant to federal law, healthcare providers are prohibited from employing individuals who have been placed on the OIG (Office of Inspector General) Exclusion List maintained by the Attorney General's Office of the United States for the EPLS (Excluded Parties List System) list. Employers have a continued obligation to do monthly checks whether employees have been placed on these lists and must maintain current information regarding the identification of their employees.
  • Have you ever been known by another legal last name?
  • Do you go by a different first name, other than your legal name?
  • Do you have knowledge of being placed on the OIG Exclusion list?

  • Please read carefully before signing:

    I certify that the above information provided is true and complete to the best of my knowledge. I understand that the facility may investigate all statements made in this document and that any false or misleading information i have provided can result in a decision to immediately discharge or lead to civil or criminal penalties as appropriate.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Browse Files
    Cancelof

  • Iowa Division of Criminal Investigation Criminal History Record Check Request

  • Date Of Birth*
     - -
    4 digit year, 2 digit month, 2 digit day
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