Comfort Home Health Care - Wildwood Grove



Wildwood Grove

Application for Employment

PERSONAL INFORMATION

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|Name_______________________________________________ Today’s Date______________ |

|Last First Middle |

|Address________________________________________________________________________ |

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|City__________________________ State______ Zip__________ Phone#________________ |

EDUCATIONAL INFORMATION

|Type of School |Name & Location of School |Number of Years |Degree or Certificate |

|High School | | | |

|Vocational Training | | | |

|College or University | | | |

NURSING APPLICANTS ONLY

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|Nursing Assistant Registration: State___________________________ Date_____________ |

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|Minnesota RN/LPN License Number_____________________________ Expiration Date____ |

EMPLOYMENT DESIRED

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|Position desired__________________ Date you can start________ Desired Salary__________ |

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|Approximately how many hours per week would you like to work?___________ |

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|Are you available to work weekends? (circle one) Yes Somewhat No |

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|Are you available to work AM’s? (circle one) Yes Somewhat No |

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|Are you available to work PM’s? (circle one) Yes Somewhat No |

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|Are you available to work nights? (circle one) Yes Somewhat No |

An Equal Opportunity Employer

EMPLOYMENT HISTORY

Starting with your most recent employer, please provide the following information:

Date Name & Address of Employer & Supervisor Position Salary Reason for Leaving

|From: | | | | |

| | | | | |

|To: | | | | |

|From: | | | | |

| | | | | |

|To: | | | | |

|From: | | | | |

| | | | | |

|To: | | | | |

|From: | | | | |

| | | | | |

|To: | | | | |

|If presently employed, may we contact your present employer? (Yes ( No |

|Have you ever been convicted of a felony? ( Yes ( No |

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|Were you ever discharged or requested to resign from any position? ( Yes ( No Reason?________________________________________________________________________ |

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|Have you every filed an application or worked here in the past? ( Yes ( No (If yes, date:___to____) |

PERSONAL REFERENCES (Please do not list relative or former employers)

Name Address Occupation Telephone

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|I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on |

|this application shall be grounds for dismissal. |

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|I authorize investigation of all statements contained herein and the references listed above to give you any and all information concerning my previous employment |

|and any pertinent information they may have, personal and otherwise, and release all parties from all liability for any damage that may result from furnishing same|

|to you. |

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|I understand and agree that, if hired, my employment Wildwood Grove is for no definite period and may, regardless of date of payment of my wages and salary, be |

|terminated at any time without any prior notice. I also understand that I may resign at any time. |

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|Signature___________________________________________________ Date_______________________ |

Wildwood Grove

Reference Request

CONFIDENTIAL REFERENCE REQUEST FOR:

(Please print.)

Applicant Name:

Name at time of employment, if different:

Employer Name:

Supervisor:

Address:

City, State, Zip:

I, have applied for a position with Wildwood Grove.

I hereby release and any of it’s employees from liability

(former employer)

relating to the release of confidential employment to Wildwood Grove. Please answer the questions to the best of your

knowledge.

Applicant Signature Date

Was applicant in your employ from __________ to __________ ? Yes_____ No_____

Was his/her title ? Yes_____ No_____

Did s/he leave because ? Yes_____ No_____

Would you rehire the applicant? Yes_____ No_____ Reason:

|Attendance………………………………………………. |Excellent | |Good | |Fair | |Poor | |

|Cooperation……………………………………………... |Excellent | |Good | |Fair | |Poor | |

|Initiative………………………………………………….. |Excellent | |Good | |Fair | |Poor | |

|Quality of Work…………………………………………. |Excellent | |Good | |Fair | |Poor | |

|Productivity……………………………………………… |Excellent | |Good | |Fair | |Poor | |

Other comments that you feel are important:

Thank you for taking the time to fill out this form. If you have any questions, or would like to speak with a Wildwood Grove representative, please call (507)324-5707.

Signature (of person completing form) Title Date

IF PHONE REFERENCE:

Name and Title of Person Referring:

Name and Title of Person Obtaining Reference:

Date

Wildwood Grove

Reference Request

CONFIDENTIAL REFERENCE REQUEST FOR:

(Please print.)

Applicant Name:

Name at time of employment, if different:

Employer Name:

Supervisor:

Address:

City, State, Zip:

I, have applied for a position with Wildwood Grove.

I hereby release and any of it’s employees from liability

(former employer)

relating to the release of confidential employment to Wildwood Grove. Please answer the questions to the best of your

knowledge.

Applicant Signature Date

Was applicant in your employ from __________ to __________ ? Yes_____ No_____

Was his/her title ? Yes_____ No_____

Did s/he leave because ? Yes_____ No_____

Would you rehire the applicant? Yes_____ No_____ Reason:

|Attendance………………………………………………. |Excellent | |Good | |Fair | |Poor | |

|Cooperation……………………………………………... |Excellent | |Good | |Fair | |Poor | |

|Initiative………………………………………………….. |Excellent | |Good | |Fair | |Poor | |

|Quality of Work…………………………………………. |Excellent | |Good | |Fair | |Poor | |

|Productivity……………………………………………… |Excellent | |Good | |Fair | |Poor | |

Other comments that you feel are important:

Thank you for taking the time to fill out this form. If you have any questions, or would like to speak with a Wildwood Grove representative, please call (507)324-5707.

Signature (of person completing form) Title Date

IF PHONE REFERENCE:

Name and Title of Person Referring:

Name and Title of Person Obtaining Reference:

Date

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