Ruthven Community Care Center
2701 East Mitchell St., Ruthven, IA 51358
Application for Employment PIN______
Please Print Empl. #______
Date of Application______Position Applying For: ______
Name______
(Last) (First) (Middle)
Address______
Phone ( )______Cell # ______Social Security Number ______/______/______
Are you at least 18 years of age? ______Yes ______No Are you at least 16 years of age? ______Yes ______No
(If under 16, can you furnish a work permit?) ______Yes ______No
Have you ever been employed here before? ____Yes ____No If yes, give dates ______
Are you employed now? ______Yes ______No If yes, may we contact your present employer? ______Yes ______No
Are you on a lay-off and subject to recall? _____Yes _____ No
Where did you hear of this position? Radio Website Local newspaper Other ______
If hired, can you submit verification of your legal right to work in the U.S.? ____Yes ____No
If hired, you will be required to submit documents sufficient to establish employment authorization and identity compliance with the Immigration Reform and Control Act of 1986. While you need not provide this proof of citizenship or immigration status at the time you are interviewed, please be prepared to assure us that you can do so immediately upon being hired.
On what date would you be available to work? ______Expected wage: $______
Are you available to work: _____ Full Time? _____ Part Time? Circle days available: S M T W T F S
What shifts? _____Day ______Afternoon _____Overnight Other______
Name, address & phone number of three references who are not previous employers, related to you, or live with you.
______
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Do you have record of founded child or dependent adult abuse or have you ever been convicted of a crime in this State or any other State? YES NO If Yes, when and where?______
Emergency contact during your work hours: Name:______
Phone # s (H) ______Cell # ______(W) ______
Address: ______Relationship ______
EDUCATION :
School Name Elementary High School College/University Graduate/ Professional
______
Years Completed: 4 5 6 7 8 9 10 11 12 1 2 3 4 1 2 3 4
(Circle)______
Diploma/Degree______
Describe Course
_ of Study:______
Educational Honors; Extra Curricular Activities; Professional Societies or other information (if unrelated to ethnic or religious groups or organizations):______
______
Special skills and qualifications, including those acquired from employment or other experience: ______
______
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PRIOR EMPLOYMENT (List ALL employment):
Start with your present or last job. Include military service assignment and/or volunteer activities. Account for all periods of unemployment. Exclude organization names which indicate, for example, race, color, religion, sex, national origin or disability.
Employer Telephone Dates Employed______Work Performed______
______(______)______From To______
Address
______
Job Title Hourly Rate/Salary
______Starting Final______
Supervisor $ $
______
Reason for Leaving, Voluntary or Involuntary? Explain
______
Employer Telephone Dates Employed______Work Performed___ _
______(______)______From To______
Address
______
Job Title Hourly Rate/Salary
______Starting Final______
Supervisor $ $
______
Reason for Leaving, Voluntary or Involuntary? Explain
______
Employer Telephone Dates Employed______Work Performed______
_
______(______)______From To______
Address
______
Job Title Hourly Rate/Salary
______Starting Final______
Supervisor $ $
______
Reason for Leaving, Voluntary or Involuntary? Explain
______
Employer Telephone Dates Employed______Work Performed______
______(______)______From To______
Address
______
Job Title Hourly Rate/Salary
______Starting Final______
Supervisor $ $
______
Reason for Leaving, Voluntary or Involuntary? Explain
______
Employer Telephone Dates Employed Work Performed______
______(______)______From To______
Address
______
Job Title Hourly Rate/Salary
______Starting Final______
Supervisor $ $
______
Reason for Leaving, Voluntary or Involuntary? Explain
______
Employer Telephone Dates Employed______Work Performed_ _
______(______)______From To______
Address
______
Job Title Hourly Rate/Salary
______Starting Final______
Supervisor $ $
______
Reason for Leaving, Voluntary or Involuntary? Explain
______
APPLICANT’S STATEMENT
I certify that the answers given in this Application for Employment are true and complete to the best of my knowledge. The facility may investigate all statements made in this Application and I understand that any false or misleading information provided may result in my immediate discharge.
In signing this Application I state and that I have read a copy of the Job Description for all jobs for which I have applied. I understand that I will be required to fulfill all aspects of any job if I am hired to perform the job. I understand that I may be required to pass an agility test. I also understand that I may be required to take a physical examination conducted by a physician of the employers choosing after I am given a qualified offer of employment.
I understand that this Application is not a contract of employment; that if hired, regardless of any oral representations to the contrary, the employment relationship between myself and the facility is terminable at will; that I have the right to terminate my employment at any time for any reason, and the facility retains the same right. Any changes to this employment relationship must be in writing. I understand that if hired I am required to abide by all rules and regulations of the facility.
*______*______
Signature of Applicant Date
PLEASE READ CAREFULLY BEFORE SIGNING
In filling out this application, you will also be requested to fill out anattached formgiving the facility permission to request a CHILD ABUSE / DEPENDENT ADULT ABUSE / CRIMINAL HISTORY back ground check on you. This background check will be used to help determine whether or not you are employable in a healthcare facility in Iowa. (Without your permission to run the background check, we can NOT consider you for employment, as this is the law in the State of Iowa.)
By my signature below, I understand and agree to the background check.
*______* ______
Applicant signature Date
AN EQUAL OPPORTUNITY EMPLOYER
Applicants are considered for, and employees are treated during employment without regard to age, race, color, creed, pregnancy, sex, national origin, religion, disability or status as a disables Vietnam-era veteran.
* * * * * * * APPLICANTS: * * *CONTINUE ON NEXT PAGE > > >
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***THIS AREA FOR OFFICE USE ONLY***
Start date:______Position:______
Shift:______FT PT: ______hrs./wk
Wage: $______/Hr.Shift differential: $1.50 - $1.00
Certified: Y N Testing: Y N On Registry: Y N State______Reg. # ______
Licensed: Y N License #______Expires______CPR Cert? Y N
______
______
Please fill out and Ruthven Community Care Center
FAX back . 2701 East Mitchell St., Ruthven, IA 51358
Thanks! Phone: 712-837-5411 FAX: 712-837-5410
APPLICANT’S STATEMENT
By way of my signature below, I hereby give this Employer the right to make a thorough investigation of all statements contained in this application, and of my past employment, education, and activities, and all records pertaining thereto; and I release from all liability all such persons, doctors, health organizations, companies, corporations and others supplying such information. I indemnify them and this Employer against any liability which might result from making such inquiry or investigation. I understand that any false answer or statement or implication made by me in this application or other required documents shall be considered cause for denial of employment or discharge, should I be hired.
Additionally, I authorize the facility to supply my employment and payroll record, in it’s sole discretion, in whole or in part, to any prospective employer, government agency, or other party with an interest that the facility deems appropriate.
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Signature of Applicant Date
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *OFFICE USE ONLY* EMPLOYMENT REFERENCE QUESTIONNAIRE
TO:______Attn: Human Resource Dept.
**ALL information provided will be kept CONFIDENTIAL**
Name: ______S.S. #______Position held: ______
Dates of employment: ______to ______? YES / NO: from______to______
Duties: ______
Termination: _____ Resigned-gave proper notice ______Resigned-no notice given _____Laid off-lack of work ______Involuntary Discharge, reason: ______
Brief evaluation of employee’s work history:______
ABOVE BELOW
_ __ SUPERIOR AVERAGE AVERAGE _ AVERAGE _ POOR___
WORK ATTITUDE-Willingness to learn
and follow instructions and work rules ______
QUALITY OF WORK – Execution of job,
completeness and accuracy______
QUANTITY OF WORK- Amount of work
successfully completed______
PERSONALITY & COOPERATION-Gets along
with co-workers, supervisors – team player______
TREATS RESIDENTS & FAMILIES WELL -
(customers) courteous & polite______
ATTENDANCE - Consider promptness, and
all absences______
DEPENDABILITY & INTEGRITY –
Trustworthy, reliable and honest______
PERSONAL HYGIENE & APPERANCE-Clothes
wrinkle free/no body odor/hair clean______
Would you rehire? ____ YES ____NO If ‘no’, why not? ______
Would you recommend the applicant for the position of______? _____YES _____NO
Remarks: ______
______
Date: ______Signed: ______Title: ______
IOWA HEALTH CARE FACILITY (135C) RECORD CHECK
Form C
ACCOUNT NUMBER ______
To:Iowa Div. of Criminal Investigation From: Ruthven Community Care Center
Bureau of Identification 2701 East Mitchell St.
Wallace State Office Building Ruthven, IA 51358
Des Moines, IA 50319
Phone: 515-281-5138 Phone: 712-837-5411
Fax: 515-242-6876 Fax: 712-837-5410
I am requesting an Iowa Criminal History check on:
T