Online Job Application - Nursing Home in IA | Decorah,

Application for Employment

Aase Haugen Senior Services is an equal opportunity Employer and Provider. It is our policy to provide equal employment opportunity to all persons regardless of age, race, religion, color, national origin, political affiliations, marital status, non-disqualifying physical or mental disability, sexual orientation, membership or non-membership in an employee organization, or on the basis of personal favoritism or other non-merit factors, except where otherwise provided by law.

Applicant Info
Education
Work Experience
References
Employment & Eligibility
Service & Background Check
Disclaimer & Signature

Last Name *

First Name *

Address *

Include the street address, city, state and zipcode

Home Phone

Cell/Mobile Phone

Email *

Position you are applying for

How did you hear about the job openings at Aase Haugen Senior Services?

Newspaper
Online Source
Word of Mouth
Referral from Current Employee

Newspaper

Online Source

Name of Employee who referred you

High School

High School Name

High School's Address

Focus of Study

Graduation or Completion Date

Diploma, Degree or Certificate Received

College

College Name

College's Address

Focus of Study

Graduation or Completion Date

Diploma, Degree or Certificate Received

Other

Name

Address

Focus of Study

Graduation or Completion Date

Diploma, Degree or Certificate Received

Professional Licenses & Certifications

Name

Address

Focus of Study

Graduation or Completion Date

Diploma, Degree or Certificate Received

Additional Affliations

Memberships & Organizations

Skills

Awards & Honors

Position Info

Do you feel that you are qualified for the position you are applying for?

Will you need any equipment or accommodations to do the job for which you are applying?

If yes, please explain

Are you willing to take education, classes or further training as required to successfully fill the position?

Beginning with the most recent job, list your past three employment positions. All supervisors may be contacted for a reference.

Employer One

Employer Name

Phone

Dates of Employment

City

Supervisor Name & Title

Job Title

Job Duties

Reason for Leaving

Employer Two

Employer Name

Phone

Dates of Employment

City

Supervisor Name & Title

Job Title

Job Duties

Reason for Leaving

Employer Three

Employer Name

Phone

Dates of Employment

City

Supervisor Name & Title

Job Title

Job Duties

Reason for Leaving

Permission to Contact

May we obtain a reference from the employers listed above?

Please give the name, address, phone number and/or email of three references NOT RELATED to you. Please notify them they may receive a call from our staff. Please sign and date three reference check authorization forms supplied with this application.

Reference One

Name

Phone

Address

Relationship

Reference Two

Name

Phone

Address

Relationship

Reference Three

Name

Phone

Address

Relationship

Are you at least 18, or can you provide proof of eligibility to work?

Have you ever submitted an application with us before?

Can you provide all proof of citizenship or a current work visa showing eligibility?

Have you been convicted of a felony within the past seven years?

If Yes, please explain

Do you have a record of founded child or dependent abuse or have you ever been convicted of a crime other than a simple misdemeanor offense relating to motor vehicles and laws under chapter 321 or equivalent provisions?

If yes, please explain

Employment

Position Desired

Employment Type

Full-time
Part-time

Shift Preferred

Hours Per Week

Date Available for work

Briefly note why you want to work for Aase Haugen Senior Services:

Military Service

Dates of Service

Indicate the beginning and ending year

Branch of Service

Special Training & Skills

Criminal Background Check Authorization

Name

Position applying for

Provide all other names/aliases you have ever been known by, including maiden or all married names:

Do you have knowledge, or have you ever been notified of being placed on the OIG Excluded Provider List or Excluded Parties List Service maintained by the General Services Administration?

If yes, for any length of time, please specify the date and reason:

Have you ever had a professional license subject to suspension or revocation?

If yes, for any length of time, please specify the date and reason:

Have you ever voluntarily relinquished your professional license?

If yes, for any length of time, please specify the date and reason:

Voluntary Survey

The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. The Information will not be used in evaluating your application or to discriminate you in any way. However, if you choose to not finish it, we are required to note the race/national origin of individual applicants on the basis of visual observation or surname. Please check all that apply.

Ethnicity/Race

Hispanic or Latino
Black/African American
Asian
White
American Indian/Alaska Native
Native Hawaiian/Other Pacific Islander
I choose not to answer

Gender

Female
Male
I choose not to answer

Applicant's Copy

Would you like to receive an email copy of this application?

You can print it straight from your email if desired.

Disclaimer & Signature

PLEASE READ CAREFULLY BEFORE SIGNING:

I certify the above answers given are true and complete to the best of my knowledge. I understand that Aase Haugen Senior Services may investigate all statements made in this application and that any false or misleading information provided can result in a decision not to hire; immediate discharge if hired; civil or criminal penalties as appropriate.

I hereby give Aase Haugen Senior Services the right to make a thorough investigation of my past health, employment, education, activities and all records pertaining thereto. I release from all liability all such persons, doctors, health organizations, companies, corporations and others supplying such information. I indemnify them and Aase Haugen Senior Services against any liability which might result from making any such inquiries or investigations initiated by my submission of this application. I understand that any false or misleading answers, statements or implications made by me in this application or other required document can result in a decision not to hire; immediate discharge if hired; civil or criminal penalties as appropriate.

Additionally, I understand that nothing contained in this application or in the granting of an interview is intended to create an employment or benefit contract of any sort between myself and Aase Haugen Senior Services. No promises regarding employment, shifts, positions or full or part-time status have been made to me.

If an employment relationship is established, I understand that I have the right to terminate my employment for any reason at any time and that Aase Haugen Senior Services retains the right to terminate my employment for any reason at any time.

If employed, I will be required to complete and Employment verification form (I-9), and show satisfactory evidence of identity and employment eligibility. I also agree to undergo a post-offer physical examination, Tuberculosis Test and Criminal Background Check. I realize that my employment is contingent upon satisfactorily passing the above-mentioned investigations and exams according to standards established by Aase Haugen Senior Services.

Applicant’s Signature

Date of Application

Name