Application for Employment | Mid-Nebraska Lutheran Home

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Mid-Nebraska Lutheran home/the Newman House
Application for employment
An Equal Opportunity Employer

We do not discriminate on the basis of race, color, religion, and national origin, sex, age or disability. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors.

Answer each question fully and accurately. No action can be taken on this application until you have answered all questions. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non job-related information.

Position you are applying for:*

How did you learn of this opening?*

Are you seeking*

Full Time Part Time or Temporary Employment

Date you can start:*

PERSONAL INFORMATION

First Name:*

Middle Initial:

Last Name:*

Street Address:*

Address 2:

City:*

State:*

Zip Code:*

Phone:*

Email:

Are you at least 18 years old?*

Yes No

(If you are hired, you may be required to submit proof of age)

Professional License Number:

License Type:

If hired, can you furnish proof that you are eligible to work in the U.S.?*

Yes No

EMPLOYMENT DETAILS

Have you ever applied here before?*

Yes No

If Yes, when did you apply?

Were you ever employed here before?*

Yes No

If yes, when where you employed here?

Have you ever been convicted of a felony or misdemeanor other than a minor traffic ticket?*

Yes No

(A criminal conviction is not an absolute bar to employment, but will only be considered in relation to the specific job.)

If yes, please give details:

(A "yes" answer does not automatically disqualify you from employment, since the nature of the offense, date, and the job for which you are applying is also considered.)

Have you ever been excluded from participating in any state or federal health care programs including Medicaid and Medicare?*

Yes No

Can you perform the essential functions of this job with or without reasonable accomodations (i.e. special equipment, lighting, etc.?)*

Yes No

Are you now or do you expect to be engaged in any other business or employment?*

Yes No

If yes, please explain:

For Driving Jobs ONLY: Do you have a valid driver's license?*

Yes No

If yes, please give driver's license details:

List professional, trade, business or civic activities and offices held:

(Exclude labor organizations and memberships which reveal race, color, religion, national origin, sex, age, disability or other protected status.)

LIST NAME AND ADDRESS OF SCHOOLS

List number of years completed, diploma/degree/certificate and subjects studied.

High School or GED:*

Did you graduate?*

Yes No

College or University:

Vocational or Technical:

What skills or additional training do you have that relate to the job for which you are applying?

What machines or equipment can you operate that relate to the job for which you are applying?

WORK EXPERIENCE

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references. Note: A job offer may be contingent upon acceptable references from current and past employers.

Are you presently employed?*

Yes No

If yes, whom do you suggest we contact?

Name of Company:

Address:

Address Line 2:

City:

State:

Zip Code:

Supervisor's Name:

Phone Number:

Job Title and Duties:

Dates of Employment (Mo/Yr)

From:

To:

Reason for Leaving:

Pay: Start $

Final $

Company Two

Name of Company:

Address of Company:

Address Line 2:

City:

State:

Zip Code:

Supervisor's Name:

Phone Number:

Job Title and Duties

Dates of Employment (Mo/Yr)

From:

To:

Reason for Leaving:

Pay: Start $

Final $

Company Three

Name of Company:

Address:

Address Line 2:

City:

State:

Zip Code:

Supervisor's Name:

Phone Number:

Job Title and Duties:

Dates of Employment (Mo/Yr)

From:

To:

Reason for Leaving:

Pay: Start $

Final $

Company Four

Name of Company:

Address:

Address 2 Company #4

City:

State:

Zip Code:

Supervisor's Name:

Phone Number:

Job Title and Duties:

Dates of Employment (Mo/Yr)

From:

To:

Reason for Leaving:

Pay: Start $

Final $

Have you worked or attended school under another name?*

Yes No

If yes, give names:

REFERENCES
List below three people not related to you.

REFERENCE #1:

First Name:*

Last Name:*

Street Address:*

Address Line 2:

City:*

State:*

Zip Code:*

Phone Number:*

Email Address:

In what capacity did you know this person?*

REFERENCE #2:

First Name:*

Last Name:*

Street Address:*

Address Line 2:

City:*

State:*

Zip Code:*

Phone Number:*

Email Address:

In what capacity do you know this person?*

REFERENCE #3:

First Name:*

Last Name:*

Street Address:*

Address Line 2:

City:*

State:*

Zip Code:*

Phone Number:*

Email Address:

In what capacity do you know this person?*

Please Read and Sign Below

I certify and agree as follows:

That this application will remain active for 30 days. If I would like to be considered for employment after 30 days, I will have to complete a new application.

That evidence of false statements or incomplete information on this application will be considered sufficient cause for immediate discharge if already employed.

That nothing contained in this application or in the interview process is intended to create in an employment contract between Mid-Nebraska Lutheran Home and myself. I understand that I have the right to terminate my employment at any time with or without notice or reason and that Mid-Nebraska Lutheran Home retains a similar right.

If hired, I understand I will be required to complete a criminal history check and pre-employment drug test. If my job requires certification and or education requirements, I am willing to complete the course and testing in a timely manner. I understand that Mid-Nebraska Lutheran Home is an equal opportunity employer. All qualified persons are welcome to submit applications for employment. Applications will be selected solely on qualifications, without regard to race, color, creed, national origin, sex, pregnancy, genetics, disability, age, religion, marital status, or ancestry.

By clicking on "I Accept", I acknowledge and consent that my electronic signature below is equivalent of my manual signature.

I Accept*

Electronic Signature

First Name:*

Last Name:*

Reference Check

I consent to having Mid-Nebraska Lutheran Home contact anyone that it deems appropriate to investigate or verify any information I have given or to discuss my background, past performance or suitability for employment. I further consent to being discussed by any person so contacted and I waive all rights to bring any action for defamation, invasion of privacy, or any similar cause against anyone contacted as a result of what he or she may say about me. I also understand that Mid-Nebraska Lutheran Home will check to determine if there is a history of past abuse of any residents.

I authorize Mid-Nebraska Lutheran Home to release specific employment information to places where I have filed an employment application, whether during or after my employment at Mid-Nebraska Lutheran Home.

By clicking on "I Accept", I'd knowledge and consent that my electronic signature below is the equivalent of my manual signature.

I Accept Reference Checks*

Electronic Signature

First Name:*

Last Name:*

CAPTCHA Code:*