Luther Manor

APPLICATION FOR EMPLOYMENT
(AN EQUAL OPPORTUNITY EMPLOYER)

LUTHER MANOR RETIREMENT COMMUNITY
3131 HILLCREST
DUBUQUE, IA 52001
563-588-1413

We offer a competitive salary, benefit and vacation package, with both part and full-time employment opportunities. Please check back periodically for new job opportunities at Luther Manor Retirement Community. Luther Manor Retirement Community is an Equal Opportunity Employer. M/F/D/V.

We comply with all applicable local, state, and federal civil rights and equal employment laws and regulations.

PERSONAL
First Name:
Middle Name:
Last Name:

Present Address
Street: City: State: Zip:

Permanent Address
Street: City: State: Zip:

Any previous name(s)?yes no
If yes, identify all other names including maiden name:


Home Phone: Contact Phone:
E-mail:

Best time to contact you:

Date you are available for work:

Are you applying for: Full-time Part-time Regular Temporary

Would you consider working: Weekends & Holidays Rotating Shifts On Call Any Shift

Shift Preference: 1st 2nd 3rd

Availability (Please check all that apply): Monday - Times Tuesday - Times Wednesday - Times Thursday - Times Friday - Times Saturday - Times Sunday - Times


EMPLOYMENT DESIRED
Position applied for:

Salary Desired:

How were you referred to this facility?

Relative or friends employed in this facility? yes no
Name: Dept: Relationship:

Have you ever been employed by this facility? yes no
If Yes, when?

Are you a U.S. citizen or an alien legally authorized to work in the United States? yes no

Long range occupational goals:


Have you ever been convicted of, plead guilty to, a crime other than misdemeanor traffic violations? yes no If yes, which state(s), and explain:


Have you ever been involved in the substantiated abuse of children or adults under the laws of this or any other state of the United States? yes no If yes, which state(s), and explain:


Have you been sanctioned, cited, reported, or excluded from participation in Medicare, Medicaid, or any other health care related law or regulation? yes no If yes, which state(s), and explain:


If your answer is "yes" to any of the above, you will not be automatically disqualified from employment consideration, except as required by state or federal law.


EDUCATION AND SKILLS

High School

Name:

Address:

Course of Study

Number of years attended:

Did you graduate? yes no
List diploma or degree

College/Other

Name:

Address:

Course of Study

Number of years attended

Did you graduate? yes no
List diploma or degree

College/Other

Name:

Address:

Course of Study

Number of years attended

Did you graduate? yes no
List diploma or degree

Other (Business college or special courses: (Include special military training, post graduate and nursing.)

Area(s) of specialization or major interest?

List office skills including computer/software experience.

List health care, business, or industrial equipment operated.

Word processing: (Approx. WPM)

Professional Licenses

Currently Licensed Currently Registered Eligible for License Eligible for Registration

Type: State: Number:Date:

License or registration ever suspended or revoked or on probation? yes no
If yes, explain:

Currently Licensed Currently Registered Eligible for License Eligible for Registration

Type:Number: State:Date:
License or registration ever suspended or revoked or on probation?
yes no
If yes, explain:


Professional Certifications

Currently Certified Eligible for Certification
Type: State:Date:
Currently Certified Eligible for Certification
Type: State:Date:

Briefly describe duties and skills acquired through military or voluntary services: (include dates).


PREVIOUS EXPERIENCE (Provide information regarding previous employment beginning with most recent employer.)

Employer 1

Job Title

Employment from to

Employer Name

Supervisor

Phone

Address

Duties:

Reason for leaving
May we contact your current employer? yes no

Please identify and explain any gaps in employment longer than three (3) months.

Employer 2

Job Title

Employment from to

Employer Name

Supervisor

Phone

Address

Duties:

Reason for leaving

Please identify and explain any gaps in employment longer than three (3) months.

Employer 3

Job Title

Employment from to

Employer Name

Supervisor

Phone

Address

Duties:

Reason for leaving

Please identify and explain any gaps in employment longer than three (3) months.

SIGNATURE

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date.

I understand that employment may be conditioned upon successful passing of a medical examination and that I may be required to satisfactorily complete a drug screening as a condition of employment.

I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information.

I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written agreement signed by an administrative representative of this facility and notarized.

Signature: Date:

Before submitting, please carefully review your information and make any necessary changes.
Thank You!