Napoleon Care Center | North Dakota Long-Term Care

Employment

NAPOLEON CARE CENTER 311 EAST 4TH STREET NAPOLEON, ND 58561 It is the policy of this facility to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability or any other reason prohibited by law.

Employment Application

Your Name*

Last, First, Middle I
Social Security #
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
If you have lived at the above address less than 12 months, list your previous 2 addresses:
Position applied for:*
Salary Desired*
1. Are you at least 18 years old?*
- Yes
- No
Are you legally authorized to work in the United States? (Proof of citizenship or right to work status will be required at time of hire).*
- Yes
- No
Review the job description for the position which you are applying. Do you meet the qualifications and have the ability to perform the essential job functions of this job?*
- Yes
- No
If no please explain:
Have you ever been convicted of or pled guilty to any criminal felony offense within the past seven years?*
- Yes
- No
Are you presently charged with any felony violations of law?*
- Yes
- No
Have you ever been convicted, disciplined, reprimanded or terminated from employment due to mistreatment of a patient or resident?*
- Yes
- No
Have you ever been convicted, disciplined, reprimanded or terminated from employment for the misappropriation of funds or other properties not belonging to you but which you had access to during your employment?*
- Yes
- No
Have you ever been convicted, disciplined, reprimanded or terminated from employment for the misappropriation of funds or other properties not belonging to you but which you had access to during your employment?*
- Yes
- No
If your response to any of the preceding three questions was “YES”, give the date, county and state where offense occurred and nature of each such conviction or pending charge. (The existence of a conviction or pending charge will not necessarily preclude you from employment; the nature of the crime and its relationship to the position applied for, the degree of rehabilitation of the applicant and the time elapsed since the crime or release from confinement will all be considered).
Date in which you can begin work:*
MM slash DD slash YYYY
Shifts you can work:*
- Select All
- Days
- Evenings
- Night
Will you work extra hours whenever scheduled or requested?*
- Yes
- No
Have you ever been employed by this nursing home?*
- Yes
- No
If yes, give position and dates employed:
Special skills you possess:*
Long range occupational goals:*
Would you accept:*
- Part-time
- Full-time
Education: High School
Did you finish?*
- Yes
- No
If not, indicate grade completed
Name of school and location
Major Subjects
Education: College
Did you finish?*
- Yes
- No
If not, indicate grade completed
Name of school and location
Major Subjects
Education: School of Nursing
Did you finish?*
- Yes
- No
If not, indicate grade completed
Name of school and location
Major Subjects
Education: Special Schooling or Training
Did you finish?*
- Yes
- No
If not, indicate grade completed
Name of school and location
Major Subjects
Professional license and certifications:
Please include Type, State, Issued, Date, Number
Have you ever been discharged from a job or forced or asked to resign?*
- Yes
- No
If yes, please explain:
Have you ever been counseled, verbally or in writing, for violation of a prior employer’s safety rules?*
- Yes
- No
If yes, please explain:
Have you ever been counseled, verbally or in writing, for violation of any company policy of a prior employer?*
- Yes
- No
If yes, please explain:
Employment History:
(List all previous employers for whom you have worked during the last five years. Explain any lapses between times when employed).
Name & Address of employers (most recent first)*
please include your: start & end date (month/yr) - salary - position / location - supervision - reason for leaving
please include your: start & end date (month/yr) - salary - position / location - supervision - reason for leaving
Have you been a CNA in another State?*
- Yes
- No
If yes, please list State(s), license # if known, and dates:
References
List the names, addresses, and telephone numbers of people we can contact for professional recommendations. List at least one employer or former employer if possible.
Name: Address: Telephone Number:*
MILITARY SERVICE RECORD
Military Service Record: The hiring and re-employment of veterans will be conducted in accordance with applicable state and federal laws and regulations.
Are you now a member of a Reserve or National Guard unit?
- Yes
- No
If yes, what branch and type of discharge:
Dates of Duty: mm/dd/yyyy to mm/dd/yyyy
List duties in the military or special training that prepared you for the position you are seeking:
CAUTION: PLEASE READ BEFORE APPLYING FOR EMPLOYMENT. I hereby state that the information given by me in this application, related papers, and interviews is true in all respects. I understand that Napoleon Care Center will investigate my work history and may verify any information given in my application, related papers or interviews. I hereby authorize my former employers to release information pertaining to my work record, my work habits, and my work performance. I agree that, if I am employed and the information I have given is found to be false in any respect, I will be subject to dismissal without notice at any time. I understand and agree that any employee handbook which I may receive will not constitute an employment contract, but will be merely a gratuitous statement of Napoleon Care Center's current policies. I understand that Napoleon Care Center reserves the right to require its employees to submit to alcohol or drug tests prior to and randomly throughout their employment with Napoleon Care Center. Napoleon Care Center also has the right to inspect bags(including purses or briefcases) or parcels brought into or taken out of the facility. I understand that refusal to submit to an alcohol/drug test or search, when requested to do so, may result in termination of my employment. I understand and agree that, if I am offered employment by Napoleon Care Center, my employment will be for no definite term and that either I, or Napoleon Care Center, will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice and that this relationship can only be modified in writing and signed by the administrator.
Please mark that you acknowledge and have read the previous statement.*
- Agree
Date*
NORTHERN TESTING - NOTICE OF CONSUMER REPORT This is to inform you that as part of our procedure for processing your employment application and at any time during your employment, Napoleon Care Center (hereafter referred to as The Employer) may obtain from a consumer reporting agency an investigative consumer report (background check) for employment purposes. In compliance with the Fair Credit Reporting Act, the reporting agency, Northern Testing, 3108 S. Broadway, Suite E, Minot, ND 58701: will not obtain such a report without your signed authorization. You understand that upon written request (within 60 days) to The Employer you will be informed whether an investigative consumer report was received and given full information as to the nature, scope and findings of the investigation. You understand that an investigative report is a report in which public and/or personal information may be obtained through personal interviews with known associates and public reporting agencies. Personal information can include, but is not limited to: Criminal & driving records, educational and employment, tests for illegal drugs, verifications, social security address trace, employment credit check, personal references, etc. By acknowledging below, you are authorizing The employer to obtain an investigative consumer report as part of the pre-employment background screening process. If The Employer offers you employment, you authorize The Employer to obtain additional investigative reports and retain those reports on file for the duration of your employment or longer if required and/or allowed by law. I hereby acknowledge that I have read the above disclosure statement and have understood it.
Please mark that you acknowledge and have read the previous statement.*
- Agree
Date*
Name
First Last
Date of Birth
MM slash DD slash YYYY
Social Security Number:
Drivers License Number:
Last Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Previous Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Date*
Please mark that you acknowledge and have read the previous statement.*
- Agree
Signature

Napoleon Care Center
PH: (701) 754-2381
311 East 4th Street
Napoleon, ND 58561

Employment

Employment Application

Education: High School

Education: College

Education: School of Nursing

Education: Special Schooling or Training

Professional license and certifications:

Employment History:

References

MILITARY SERVICE RECORD