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Application for Employment

999-999-9999
999-999-9999
Positions(s):
Lutheran Care
Presbyterian Homes

mm/dd/yyyy
Referral Source:










(include am or pm)
At which number?
May we contact you at work?

If yes, work number and best time to call:

(include am or pm)
If you are under 18 and it is required, can you furnish a work permit?


Have you submitted an application here before?


Have you ever been employed here before?

If yes, please give date(s):




Is this application a request for reemployment following an extended military leave of absence from this company?
Are you legally eligible for employment in this country?

mm/dd/yyyy

$
Type of employment desired:



Desired Shift:



Will you relocate if the job requires it?

Will you travel if the job requires it?

If they have been explained to you, are you able to meet the attendance requirements of the position?:




Will you work overtime if required?


Are you able to perform the "essential functions" of the job for which you are applying (with or without reasonable accommodation)?:




Driver's license number required if driving may be required in the job for which you are applying:

Have you ever been bonded?

Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.
Have you ever pleaded "guilty" or "no contest" to, or been convicted of, a crime?


Have you entered into an agreement with any former employer or other party (such as a noncompetition agreement) that might, in any way, restrict your ability to work for our company?


Employment History

Employer 1

Begin with your current or most recent employer.

999-999-9999
Reason for Leaving:




(for most recent position)
May we contact for a reference?

Dates Employed:
Compensation (Final)





Employer 2
999-999-9999
Reason for Leaving:




(for most recent position)
May we contact for a reference?

Dates Employed:
Compensation (Final)





Add another employer

If not addressed above, have you ever been fired or asked to resign from a job?


Skills and Qualifications


Computer Skills (Check appropriate boxes. Include software titles and years experience.)




Educational Background

School 1

Begin with your current or most recent school attended.

Are you still attending?:


Completed


Add another school

References

List names and telephone numbers of two professional references and two personal references who are not related to you and are not previous supervisors. If not applicable, list school or personal references who are not related to you.

Professional Reference 1
999-999-9999
Professional Reference 2
999-999-9999
Personal Reference 1 (non-relative)
999-999-9999
Personal Reference 2 (non-relative)
999-999-9999

Related Information



Resume

Upload a Word, WPS or PDF copy of your resume.
Were you ever EXCLUDED or are you pending EXCLUSION from Medicaid or Medicare billing?


Licenses/Certificates:



Applicant Statement

It is understood that an omission of facts or false statements made as part of the application process will be grounds for dismissal from any subsequent employment by LutheranCare.

DO NOT CHECK THE BOX UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT.

Please click submit only once. It may take up to 30 seconds to collect your information. You will receive an on-screen confirmation when complete.