2025 Application for Employment - Hiawatha Care Center

Hiawatha Care Center Application for Employment
Date of Application*

MonthDayYear
Date
Position Applying For*
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
SSN #*
ex. 987-65-4321
Date Of Birth*

YearMonthDay
Date
Email*
example@example.com
Are you at least 18 years of age?*

YesNo
Are you at least 16 years of age?*

YesNo
If less than 16 do you have a work permit?*

YesNo
Have you ever been employed here before?*

YesNo
If yes, give a date.*

MonthDayYear
Date
Are you employed now?*

YesNo
May we contact your current employer?*

YesNo
Can you, if hired, submit verification of your legal right to work in U.S.?

YesNo
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?*

YearMonthDay
Date
Expected Salary*
Work Schedule Availability*

Full-TimePart-Time
If temporary, what days?

SundayMondayTuesdayWednesdayThursdayFridaySaturday
If temporary, what hours?

DaysEveningsOvernightsOther
Are you on a lay off and subject to recall?*

YesNo
Give name, address, and telephone number of three references who are not related to you and are not previous employers.
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)*

YesNo
Have you ever been convicted of a crime in this state of any other?*

YesNo
Do you have a record of founded child or dependent adult abuse?*

YesNo
Signature*

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Signature
Date*

YearMonthDay
Date

Education Level

	Name & Address of School	Course of Study	Years Completed	Diploma /Degree
High School
Undergraduate College
Graduate Professional
Other (Specify)

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
Employer (Employer 1)
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number
Job Title
Supervisor
Reason for Leaving
Employer Start Date

MonthDayYear
Date
Employer End Date

MonthDayYear
Date
Work Performed
Starting Wage
Ending Wage
Employer (Employer 2)
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number
Job Title
Supervisor
Reason for Leaving
Employer Start Date

MonthDayYear
Date
Employer End Date

MonthDayYear
Date
Work Performed
Starting Wage
Ending Wage
Employer (Employer 3)
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number
Job Title
Supervisor
Reason for Leaving
Employer Start Date

MonthDayYear
Date
Employer End Date

MonthDayYear
Date
Work Performed
Starting Wage
Ending Wage
Additional Information
State any additional information you feel may be helpful to us in considering your application. Summarize special job-related skills & qualifications from employment or other experience
Signature*

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Date*

MonthDayYear
Date
New Employee or Change of Employee Information Worksheet
Full Name*

Legal First NameMiddle NameLegal Last Name
SSN #*
ex. 987-65-4321
Maiden Name
Date of Birth*

MonthDayYear
Date
Professional License # / State
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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?

YesNo
Other Legal Last Name(s)
Do you go by a different first name, other than your legal name?

YesNo
Other Legal First Name(s)
Previous State you have worked in
Do you have knowledge of being placed on the OIG Exclusion list?

YesNo
If so, when? Please explain
Have you ever had a professional license subject to suspension or revocation?
If so, please explain
Have you ever voluntarily relinquished your professional license?
If so, please explain
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.
Initial Signature*

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Date*

MonthDayYear
Date
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Hiawatha Care Center Application for Employment

Employment Experience

New Employee or Change of Employee Information Worksheet

Please read carefully before signing: