Join Our Team Step 1 of 5 - Personal Information 20% Date of Application* MM slash DD slash YYYY Date Available for Work* MM slash DD slash YYYY Name* First Middle Last Address* Street Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* Location of Interest*Gracewell (Nursing Facility)Silveridge (Assisted LIving Facility)Select your location(s) of interestAreas of Interest*RNLPNNursing AssistantTenant CompanionLaundry | HousekeeperActivitiesMaintenanceDietaryClericalManagerialUniversal WorkerOtherSelect your area(s) of interestWork Shift Desired Hourly Rate/Salary Desired How did you learn of opening? Will you accept employment for:*Full TimePart-TimeTemporaryAre you 16 years of Age or older?* Yes No Have you filed an application here before?* Yes No Please give date: Have you ever been employed here before?* Yes No Please give date: Are you employed now?* Yes No May we contact present employer? Yes No Years Completed Select highest completedElementary 5 6 7 8 High School 9 10 11 12 College/University 1 2 3 4 Graduate/Professional 1 2 3 4 Name of School Location Type of Degree or Certificate Were you in the U.S. Armed Forces? Yes No What branch? Please describe any specialized training, apprenticeship, skills and extra-curricular activities you have held: Present & Former EmployersEmployer Phone NumberAddress Supervisor Hourly RateStarting Final Dates EmployedFrom To Position & DutiesReason for LeavingPresent & Former EmployersEmployer Phone NumberAddress Supervisor Phone NumberHourly RateStarting Final Dates EmployedFrom To Position & DutiesReason for LeavingPresent & Former EmployersEmployer Phone NumberAddress Supervisor Hourly RateStarting Final Dates EmployedFrom To Position & DutiesReason for Leaving If hired, you will be required to submit documents sufficient to establish employment authorization and identity in compliance with the Immigration Reform and Control Act of 1986. This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.Consent* These answers are true and complete to the best of my knowledge.Eventide Lutheran Home for the Aged may investigate all statements contained in this application, and I understand that any false or misleading information provided may result in immediate discharge. I UNDERSTAND THIS APPLICATION IS NOT A CONTRACT OF EMPLOYMENT AND THAT IF HIRED, REGARDLESS OF ANY ORAL REPRESENTATIONS TO THE CONTRARY, THE EMPLOYMENT RELATIONSHIP BETWEEN ME AND EVENTIDE LUTHERAN HOME FOR THE AGED IS TERMINABLE-AT-WILL. ANY CHANGES IN THIS EMPLOYMENT RELATIONSHIP MUST BE MADE IN WRITING. I also understand that any offer of employment may be conditioned upon a health evaluation by a doctor selected by the applicant to determine whether I can perform my job duties. Additionally, I authorize Eventide Lutheran Home for the Aged to supply my employment record, in its sole discretion, in whole or in part, to any prospective employer, government agency, or other party, with an interest that Eventide Lutheran Home for the Aged deems appropriate.Approved by Eventide Board of Directors 12/15/03
