Employment

Hackensack Senior Class is a very rewarding place to work. Please print and fill out the following application and fax it to 218-675-5184

_________________________________ _________________

Name of Applicant (Please Print) Today’s Date

Hackensack Senior Class

Application

For Employment

Hackensack senior Class is an affirmative action/equal opportunity employer and hires qualified individuals without regard to race, color, creed, marital status, and status with regard to public assistance, sex, age, national origin, religion, disability, ancestry, veteran/military status, sexual orientation or any other protected classes.

The use of this application form does not indicate that there are any positions open and does not in anyway obligate you or this facility.

I. Job Interest:

Position Applied For: (Please check all that apply)

______ RN _____LPN _____Nurse Aide

_____Housekeeping _____Cook/Kitchen Help

_____Maintenance _____Other (Please Specify) ________________________

Would you be willing to cross train? _____Yes _____No

I am interested in: (Please Check All That Apply)

_____Full Time _____Part Time _____Temporary/Seasonal _____On Call (as needed)

What Hours Are You Available To Work? From: ________________________________

To: ________________________________

Are You Available To Work? (Please Check All That Apply)

_____Evenings _____Nights _____Weekends

Date Available to Begin Work: _________________________________________

II. PERSONAL:

Print Name: ___________________________________________________________________________________

(Last) (First) (Middle)

Address: _____________________________________________________________________________________

(Street) (City) (State) (Zip)

Telephone No: (Home) ____________________________ (Cell) _____________________________

E-Mail Address: _______________________________________________________________________________

Are you 18 years of age or older: _________________________________________________________________

Gender: ˜ Male ˜ Female MN Drivers License/MN State ID: ___________________________________

III. EDUCATION:

Name(s) of Educational Institutions	Location	Curriculum/Major	Highest Grade or Degree Completed
High School
College Or University
Trade Or Vocational
Business Or Other

IV. SPECIALIZED Training:

List all licenses, areas of certification or any other special training: _________________________________

______________________________________________________________________________

Additional comments/reasons why you would like to work here: __________________________________

_____________________________________________________________________________

What other Personal talents, experiences or interests that you would like us to know about? ________________

_____________________________________________________________________________

V. Background:

Have you ever been convicted of a felony? ˜ Yes ˜ No If yes, Date of Conviction: ___________________________

(A record of a conviction of a misdemeanor or felony may not disqualify you from consideration for employment in this facility.)

VI. PAST Employment:

Please indicate a continued record of employment, beginning with your most recent position. Include what you have done for the last 5 years, or from the time you left school. If you need additional space, please attach another sheet.

Employer’s Name	From Mo./Yr.	To Mo./Yr.	Rate of Pay	Address and Phone Number	Job Title and/or Duties	Reason for Leaving
Name: Supervisor:
Name: Supervisor:
Name: Supervisor:
Name: Supervisor:

If you are currently employed, may we contact your present employer? ˜ Yes ˜ No

VII. REFERENCES:

Please list the names of three persons not related to you and whom you have known at least one year.

Name Address Phone

1. _________________________________________________________________________________________

2. _________________________________________________________________________________________

3. _________________________________________________________________________________________

Please read this section before signing!

Falsification of Records

This application was completed by me and I certify that the information in this application is correct to the best of my knowledge. I understand that falsification of this application or omission of requested information in any detail is grounds for disqualification from further consideration or for dismissal from employment.

Conditional Offer of Employment

If I receive a conditional offer of employment, I understand that I may be the subject of drug screening, criminal background study and/or physical screening and evaluation, and I hereby consent to such screening and record checks.

Proof of Right to Work

If I am offered a position with Hackensack Senior Class, I understand that as a condition of employment I will be required to prove identity and right to work as required by the Immigration Reform and Control Act of 1986.

Participation in Government Programs

I agree to inform my supervisor or administrator if I become subject to exclusion from any Federal or State Health Care Program [as defined by 42 U.S.C. 1320a-7] as a vendor, provider, or employee or contractor of a participating provider or if I become aware that I may be subject to such exclusion.

RELEASE OF INFORMATION

I acknowledge that consideration for employment is contingent on the results of a reference and background check.

Therefore, I hereby authorize Hackensack Senior Class to (1) investigate the truthfulness of all statements made on this application; (2) contact my former employers and other listed references or any other persons who can verify information; and (3) discuss the results of any investigation with other employees of Hackensack Senior Class involved in the hiring process. In addition, I give my consent for all contacted persons including former employers to provide information concerning this application, and I release each such person from liability for providing information to Hackensack Senior Class.

To Be Completed at the time of the interview

I acknowledge I have read and understand the essential job duties for the position for which I have applied.

Signature _________________________________________________ Date ______________________

DHS Background Check – Required Info

(Items marked with asterisk (*) are optional)