Application for Employment

All applicants will be considered for employment without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, status with regard to public assistance, membership on a local Human Rights Committee, sexual orientation or familial status, or any other legally protected status. We are an Equal Opportunity Employer.

OAK TERRACE RETIREMENT COMMUNITIES OF GAYLORD ARE “SMOKE FREE” FACILITIES

If you are human, leave this field blank.

Date:

If other, please specify:

Location:

Mankato

Gaylord

Jordan

Le Sueur

Last Name:

First Name:

Middle Name:

Address: Street, City, State, Zip Code

Phone Number: Home

Phone Number: Cell

Email address where you can be reached:

Are you of legal age to work?

Yes

Do you have the legal right to be employed in the United States?

Yes

If offered a position, the Immigration Reform and Control Act of 1986 requires you to furnish proof of your employment authorization and your identity before you can begin work.

Range of pay expected: $

Have you ever been employed by Oak Terrace?

Yes

If yes, when?

Hours you are available to work:

	Start Time	End Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Amount of hours you desire to work each week?

If your application is considered favorable, on what date will you be available to work? (Answer in DD/MM/YYYY format)

EDUCATION HISTORY

	Name & Location of School	Years Completed	Major	Diploma/Degree
High School
College/University
College/University
Other Training/Education

RNs, LPNs, and CNAs please provide current professional license (if applicable) and when it expires:

Current State Professional License Number:

Expiration Date:

WORK HISTORY

Please list three of your previous work experiences, beginning with the most recent:

May we contact your present employer?

Yes

Work History

	Employer	Phone	From	To	Address: City, State, Zip	Supervisor	Position	Duties	Starting Salary/Wages	Final Salary/Wages	Reason for leaving
One
Two
Three

I, hereby, give my permission to contact the employers listed above concerning my prior experience.

Name/Signed:

If there is a particular employer(s) you do not wish us to contact, please indicate which one(s) below:

APPLICANT’S CERTIFICATION AND AGREEMENT

I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions or misrepresentations may result in my dismissal. I authorize Oak Terrace Health Care to make an investigation of any of the facts set forth in this application.

This Application for Employment is not a contract and cannot create a contract. If employed by Oak Terrace Health Care, I agree to abide by it’s policies and procedures. I understand that my employment at Oak Terrace Health Care is “at will”, which means either I or Oak Terrace Health Care can terminate the employment relationship at any time, with or without prior notice, with or without cause for reason not prohibited be statute.

I understand that any offer of employment made to me is conditional until I successfully complete the fit to work screen, drug testing, background check and provide proof that I may legally be employed in the United States.

I understand that if I am employed that emergency conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling change as directed by my department manager.

I understand that this Application for Employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I certify that I have read and agree to the above Applicant's Certification and Agreement..

Name of current employee:

If other, please specify:

Interviewed by:

Email Address

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