CMSC Online Employment Application Revised

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Central Minnesota Senior Care Online Employment Application

*We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, martial or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.

Date (CMSCOEA)

Month

Day

Year

Position(s) Applied For:*

Name (CMSCOEA)*

First Name*

Middle Name*

Last Name*

Address (CMSCOEA)* Address Line 1*
Address Line 2

City

State

ZIP Code

Home Phone (CMSCOEA)*

Alternate Phone (CMSCOEA)

Email (CMSCOEA)*

Are you over the age of 18? (CMSCOEA)*

Yes No

Are you 21 or older? (CMSCOEA)*

Yes No

Have you ever filed an application with us before?*

Yes No

If yes, why did you leave?*

Are you currently employed?*

Yes No

May we contact your present employer?*

Yes No

On what date could you be available for work?*

Month

Day

Year

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

Yes No

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Additional Questions

If hired at Central Minnesota Senior Care, you may be assigned to varied duties for time to time. Is there any work you will not perform? (AQ1)*

Yes No

If yes, please explain. (AQ1)*

If hired at Central Minnesota Senior Care, can you furnish proof that you are eligible to work in the United States? (AQ2)*

Yes No

If no, please explain. (AQ2)*

If hired at Central Minnesota Senior Care, are you prepared to provide you medical history and take a physical exam, including a drug and alcohol screening? (AQ3)*

Yes No

If no, please explain. (AQ3)*

Have you ever been convicted of a crime? (do not list minor traffic violation) (AQ4)*

Yes No

If yes, please explain. (AQ4)*

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Your Interest in Central Minnesota Senior Care

What type of position are you applying for?*

Full-time Part-time Either

What date could you start?*

Month

Day

Year

When would you like to work?*

Mornings Days Evenings Overnights Weekends

How many hours can you work weekly?

Would you like to work at a particular Central Minnesota Senior Care location?*

Yes No

If yes, please list your preferences.*

Can you travel if your job requires it?*

Yes No

Are you willing to relocate? *

Yes No

Have you ever visited a Central Minnesota Senior Care location?*

Yes No

If yes, please describe your experience.*

What unique qualifications, skills, experience or interests do you bring to Central Minnesota Senior Care?

Why would you like to work for Central Minnesota Senior Care?

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Employment

Please give and accurate, full-time and part-time record. Start with your present or most recent employer.

Employer 1

Employer (E1)

Phone (E1)

Address (E1) Address Line 1
Address Line 2

City

State

ZIP Code

Supervisor's Name and Title (E1)

Hourly Rate Starting (E1)

Hourly Rate Ending (E1)

Employment (Month/Year) From (E1)

Month

Year

Employment (Month/Year) To (E1)

Month

Year

Describe the work you did (include skills that you could apply at Central Minnesota Senior Care) (E1)

Explain your reason for leaving (E1)

May we contact this employer? (E1)

Yes No

If no, why not? (E1)*

Employer 2

Employer (E2)

Phone (E2)

Address (E2) Address Line 1
Address Line 2

City

State

ZIP Code

Supervisor's Name and Title (E2)

Hourly Rate Starting (E2)

Hourly Rate Ending (E2)

Employment (Month/Year) From (E2)

Month

Year

Employment (Month/Year) To (E2)

Month

Year

Describe the work you did (include skills that you could apply at Central Minnesota Senior Care) (E2)

Explain your reason for leaving (E2)

May we contact this employer? (E2)

Yes No

If not, why not? (E2)*

Employer 3

Employer (E3)

Phone (E3)

Address (E3) Address Line 1
Address Line 2

City

State

ZIP Code

Supervisor's Name and Title (E3)

Hourly Rate Starting (E3)

Hourly Rate Ending (E3)

Employment (Month/Year) From (E3)

Month

Year

Employment (Month/Year) To (E3)

Month

Year

Describe the work you did (include skills that you could apply at Central Minnesota Senior Care) (E3)

Explain your reason for leaving (E3)

May we contact this employer? (E3)

Yes No

If not, why not? (E3)*

Employer 4

Employer (E4)

Phone (E4)

Address (E4) Address Line 1
Address Line 2

City

State

ZIP Code

Supervisor's Name and Title (E4)

Hourly Rate Starting (E4)

Hourly Rate Ending (E4)

Employment (Month/Year) From (E4)

Month

Year

Employment (Month/Year) To (E4)

Month

Year

Describe the work you did (include skills that you could apply at Central Minnesota Senior Care) (E4)

Explain your reason for leaving (E4)

May we contact this employer? (E4)

Yes No

If not, why not? (E4)*

General Employment

Have you ever been discharged by an employer? (GE)*

Yes No

If yes, explain. (GE)*

List all periods of unemployment. (GE)

How did you spend this time? (GE)

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Education

High School (Education)

Address (Education) Address Line 1
Address Line 2

City

State

ZIP Code

Years Completed (Education)

Did you Graduate? (Education)

Yes No

College/Vocational School (Education)

Address (Education) Address Line 1
Address Line 2

City

State

ZIP Code

Years Completed (Education)

Did you Graduate? (Education)

Yes No

Course of Study (Education)

Degree Earned (Education)

Have you completed any other courses or training programs that would impact your work at Central Minnesota Senior Care? (Education)

Yes No

If yes, please explain. (Education)

List any foreign languages you can speak, read or write. (Education)

List any membership in Professional, Educational, or Civic Organizations, offices held, or honors achieved. (Education)

Exclude those which may disclose your race, color, religion, or national origin

Personal References

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

Name (R1)

First Name

Last Name

Address (R1) Address Line 1
Address Line 2

City

State

ZIP Code

Phone (R1)

Name (R2)

First Name

Last Name

Address (R2) Address Line 1
Address Line 2

City

State

ZIP Code

Phone (R2)

Name (R3)

First Name

Last Name

Address (R3) Address Line 1
Address Line 2

City

State

ZIP Code

Phone (R3)

Please Read before you submit this form.

I certify that answers given herein are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
This application for employment shall be considered active for a period 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 hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will” nature, which means that the employee may resign at any time and the employer may discharge employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless an authorized executive of this organization specifically acknowledges such change in writing.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

I agree that the answers given herein are true and complete to the best of my knowledge.*

Yes No

Referral Source

Walk-in
Government Employment Agency
Relative
Employee
Private Employment Agency
School
Advertisement
Other

Please list Advertisement source:

If other

Name of person who referred you (if applicable)

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Affirmative Action Voluntary Information

Divine House considers all applicants for positions without regard to race, color, religion, sex national origin, citizenship, age, mental/physical disabilities, veteran/reserve/national guard or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria.

To be completed by applicant on a voluntary basis. Not for interview purposes. To be filed separately from application.
In an effort to comply with requirements regarding government record keeping, reporting, and other legal obligations which may apply, we invite you to complete this applicant data survey. Providing this information is STRICTLY VOLUNTARY. Failure to provide it will not subject you to any adverse personnel decision or action. Your cooperation is appreciated.
Employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap or any other legally protected status.
As an employer with an Affirmative Action Program, we comply with government regulations, including Affirmative Action responsibilities where they apply.
The purpose for this Data Record is to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the government on the following information. The completion of this Data Record is optional. If you choose to volunteer the requested information please note that all Data Records are kept in a confidential file and are not a part of your application for employment or personnel file.
Please Note: YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.

This survey is not a part of your application for employment. It will not be used in any hiring decision. The information will be used and kept confidential in accordance with applicable laws and regulations.

Position(s) applied for: (Affirmative Action)

Date (Affirmative Action)

Month

Day

Year

Applicant Information

Name

First Name

Last Name

Address Address Line 1
Address Line 2

City

State

ZIP Code

Telephone Number

Gender (AI)

Male Female

Please Check One of the Following:

White
Black
Asian/Pacific Islander
Hispanic
American Indian/Alaskan Native (not of Hispanic origin)