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Employment Application
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PERSONAL INFORMATION
Applicants will receive consideration for employment without regard to race, color, national origin, creed or religion, sex, marital status, age, handicap or any other personal characteristics protected by federal, state or local laws. We encourage the employment of veterans of the United States Armed Forces and all other qualified applicants. The employer will not refuse to hire a disabled applicant who is capable of performing the essential requirements of the job with or without reasonable accommodations. You are not required to disclose information about physical or mental limitations that you believe will not interfere with your ability to do the job. On the other hand, if you want the employer to consider special arrangements to accommodate a physical or mental impairment, you may identify that impairment in the space provided and suggest the kind of accommodation you believe would appropriate. Providing this information is strictly voluntary. If provided, it will be kept confidential. Refusal to provide this information will not subject applicants to adverse treatment. Applicants are kept on the file for a minimum of one year. You may update your application upon request. False statements or omission of requested information on this application form shall be considered sufficient cause for rejection during the hiring process. If false statements or omission are discovered after hire, they shall be considered sufficient cause for termination of employment. Applicants will be considered at the time of receipt. If you wish to update your application or request additional consideration, you must contact the facility.
Last
*
First
*
Middle
Date
Address
Street or P.O. box, City, State and Zip code
Phone(s)
Email
Are you authorized to work for wages in the United States?
Yes
No
If you answered "Yes" you will be required to present documentation showing your employment authorization and identity. Age is not used as hiring criteria unless required by law. If you are under 18, you may be required to prove your age for some jobs where state safety standards make restrictions. In some states, you may be required to present a work permit. Mountain Lodge, LLC has no mandatory retirement age. If you are eligible for Social Security benefits, Medicare or over 65, your wages and benefits from DCC could affect your government program benefits. We are proud to employ staff in their seventies and eighties.
Referral Source
State Job Service
Ad
Current Staff Member
None-Walk-in
Other
Please list referring employee name
Note: All persons are subject to a drug test and background check prior to employment.
Work Desired
Type of work or position(s) desired:
Full-time
Part-time
Temporary
Dates you can start permanent employment:
Dates of temporary employment availability:
Scheduling: Normal office hours are maintained Monday thru Friday in our Business Office with the exception of some weekend, evening, and night shift work. Every nursing facility must be staffed 7 days a week, 24 hours a day. Work schedules are varied and require flexibility. Based on our staffing needs, we may not always be able to accommodate your scheduling preferences. Therefore, please consider carefully all of your personal time/commitments before responding to the following questions.
Shift(s) You Can Work
Days
Evenings
Nights
No preference, I can work any shift
2nd Choice
None
Days
Evenings
Nights
Can you rotate shifts?
Yes
No
Indicate all the days you would be able to work:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Work Experience/References
Have you ever worked for Mountain Lodge, LLC before?
Yes
No
If yes, where and dates worked?
Position held:
Immediate Supervisor:
Reason for Leaving:
List most recent employer first. Include military service if among last four jobs. You may list volunteer experience if you do not have paid work experience with four employees. Write "V" in the salary column.
EMPLOYMENT #1
Employer
Address
Phone
Dates of Employment
Enter a start date and an end date.
Job Title
Supervisor's Name/Job Title
Primary Job Duties
Final Salary $
Reason for Leaving
May we contact for a reference?
Yes
No
If not, please explain:
EMPLOYMENT #2
Address
Phone
Dates of Employment
Please enter the start date and the end date.
Job Title
Supervisor's Name/Job Title
Primary Job Duties
Final Salary $
Reason for Leaving
May we contact for a reference?
Yes
No
If not, please explain:
EMPLOYMENT #3
Address
Phone
Dates of Employment
Enter a start date and an end date.
Job Title
Supervisor's Name/Job Title
Primary Job Duties
Final Salary $
Reason for leaving
May we contact for a reference?
Yes
No
If not, please explain:
EMPLOYMENT #4
Address
Phone
Dates employed
Enter a start date and an end date.
Job Title
Supervisor's Name/Job Title
Primary Job Duties
Final Salary $
Reason for leaving
May we contact for a reference?
Yes
No
If not, please explain:
Lisa any other references we may contact (We will not employ relatives in a position where a direct supervisory relationship will exist)
Explain any circumstances(s) that may affect reference received:
LICENSURE
LICENSED PRACTICAL NURSE
State Number/Expiration Date
REGISTERED NURSE
State Number/Expiration Date
CERTIFIED NURSES ASSISTANT
State Number/Expiration Date
Administrator
State Number/Expiration Date
RPT
State Number/Expiration Date
Other
If you don't have a license, have you applied?
Yes
No
If exam is required, give schedule date:
If not licensed in this state, have you applied for reciprocity?
Yes
No
Are there any current restrictions, or have there been any restrictions in the past placed on any license listed above?
Yes
No
If yes, please explain:
Are there any current complaints, or have there been any complaints in the past placed on any license listed above?
Yes
No
If yes, please explain:
SKILLS
Please check ALL items in which you have training and/or experience
Supervision of Employees
Teaching
Accounts Payable
Accounts Receivable
Payroll
Full Charge Bookkeeping
Financial Statements
Cost Reporting
Auditing
Taxes
Budgeting
Shorthand/Speedwriting
Diction Equipment
10 Key Adding Machines
Calculator
Key Punch Machines
Switchboard
Copy Machines
Clinical Skills
Blood Pressure
T.P.R.
Feeding Disabled Patients
Transfer Techniques
Alignment & Positioning
Range of Motion
B & B Training
Catheterization
Medicare/Medicaid Reimbursement
Medical Records
Insurance Billing
Typing
Typing WPM
Skills
Dictation equipment
10 key adding machines
Calculator
Key punch machines
Switchboard
Copy machines
Long Term Care/Rehabilitation Nursing Techniques
Administration of Medicine
Isolation Techniques
Sterile Techniques
Reality Orientation
Therapeutic Activity Programs
Use of P.T. in Long Term Care
Use of O.T. in Long Term Care
Charting
Patient Care Plans
Data Processing
Word Processor
Computers
EDUCATION
School/Location and Type of Degree
Relevant Courses
School/Location and Type of Degree
Relevant Courses
School/Location and Type of Degree
Relevant Courses
Other Education (Seminars, Military, Schools, etc.)
I have read all sections of this application and authorize verification of my statements. I understand that misrepresentation may be considered cause for rejection in the hiring process or termination of employment. I further understand my employment may be subject to a physical examination, drug screening, favorable references and documentation of my right to work in the U.S. if a bonafide job offer is made. In consideration of my employment, I agree to conform to the rules, procedures, and regulations of Mountain Lodge, LLC. I understand that my employment and compensation can be terminated with or without cause, and or without notice, at any time, at the option of either the facility or myself I understand that no representative of Mountain Lodge, LLC other than the Administrator/Board of Directors has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.
Signature and Date
Interviewed by:
Name/Job Title/Date
Interviewed by:
Name/Job Title/Date
Interviewed by:
Name/Job Title/Date
Resume
Accepted file types: pdf, Max. file size: 39 MB.
Please attach your resume here.
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