Nursing Application

Employment Information

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status. sexual orientation or anv other leaallv protected status.

Position(s) Applied For:

Certified Nurse Assistant (CNA)

LPN and RN Nurses

Date of Application

First Name

Middle Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Social Security Number

Are you 16 years of age or older?

Yes

Do you possess a valid Driver's License?

Yes

Are you legally eligible to work in the United States?

Yes

Have you ever filed an application with us before?

Yes

If Yes, give date

Have you ever been employed with us before?

Yes

If Yes, give date

Are you currently employed?

Yes

May we contact your current employer?

Yes

What other states have you worked in?

Are you available to work:

Full Time

Part Time

Evening Shift

Dayshift

Nightshift

Fill In

How did you learn about us?

Friend

Walk-In

Employment Agency

Relative

Social Media

Other

Employment Experience

Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status. If you have no work experience, list 2 references with people who know you that have supervising experience i.e. teacher, parent you babysat for, etc.

Employment 1

Upload your Cv/Resume

Choose File

Previous Employer

Date Employed

Date of Leaving Job

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Job Title

Supervisor

Hourly Rate/Salary

Roles and Responsibilities

Reason for Leaving

Employment 2

Previous Employer

Date Employed

Date of Leaving Job

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Job Title

Supervisor

Hourly Rate/Salary

Roles and Responsibilities

Reason for Leaving

Employment 3

Previous Employer

Date Employed

Date of Leaving Job

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Job Title

Supervisor

Hourly Rate/Salary

Roles and Responsibilities

Reason for Leaving

Explain Gaps in Employment History

References and Education

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? (DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.)

Yes

References

Name

Phone/Mobile

Name

Phone/Mobile

Name

Phone/Mobile

Education

Highest Grad Level Completed

GED

College/Trad School Name

Major Subjects or Degrees

Date of Enrollment

Did you Graduate?

Yes

Other Education (if applicable)

Professional or Technical License Held (if applicable)

Type

License #

Renew #

State

Expires

Fill Out if Applying to the Nursing Department

Have you ever been arrested, charged, or convicted of a felony? (You must answer yes if the felony arrest or felony charge resulted in a plea agreement, misdemeanor, nolo contendere, deferred imposition, or other action) within the cast two years

Yes

Since you last renewed, or if this is your first renewal, has your registration or nursing license been sanctioned or disciplined by any other jurisdiction?

Yes

Since you last renewed, or if this is your first renewal, have you been investigated or are you presently being investigated by any other jurisdiction?

Yes

Since you last renewed, or if this is your first renewal, have you been denied registration or nursing licensure by any other jurisdiction?

Yes

Since you last renewed, or if this is your first renewal, have you been terminated from a nursing related job due to conduct that may be grounds for disciplinary action?

Yes

Have you, in the last two years, been diagnosed with chemical dependency or participated in chemical dependency treatment/rehabilitation?

Yes

Have you, in the last two years, been diagnosed with or treated for a mental health or physical condition which has adversely affected your ability to safely assist in the practice of nursing?

Yes

If you answered "yes" to any of the questions 1-7 above, have you submitted a detailed written explanation and any legal documents to the North Dakota Department of Health.

Yes

I understand and agree that

Any material misrepresentation or deliberate omission of a fact in my application may be justification for refusal, or if employed, termination from employment.

It is my understanding that Marian Manor will make an investigation of my work history, including a background check and may verify all data given in my application for employment, related papers, or oral interviews. I authorize such investigation and the giving and receiving of any information requested by Marian Manor and I release from liability any person giving or receiving any such information. I understand that falsification of data so given other derogatory information discovered as a result of this investigation may prevent my being hired, or if hired, may subject me to immediate dismissal.

I agree that my employment may be terminated by this company at any time without liability for wages or salary except such as may have been earned at the date of such termination. If requested by the management at any time, I agree to submit to search of my person or of any locker that may be assigned to me, and I hereby waive all claims for damages on account of such examination.

Although management makes every effort to accommodate individual preferences, business needs may at times make the following conditions mandatory: overtime, shift work, a rotating work schedule, or a work schedule other than Monday through Friday. I understand and accept these as conditions of my continuing employment.

I further understand that this is an application for employment and that no employment contract is being offered.

I understand that if I am employed, such employment is for no definite period of time and that Marian Manor can change wages, benefits and conditions at any time.

I have read and understand the above.

First Name

Last Name

Today's Date

I have applied to Marian Manor HealthCare Center for employment consideration. In order that they may better evaluate my qualifications, I wish that they be fully advised of my record with you.

I hereby respectfully request that you furnish the necessary information and authorize its release without penalty or liability due to an invasion of privacy or civil rights.

First Name

Last Name

Today's Date

I have read and agree to the Terms and Conditions and Privacy Policy

I consent to have Marian Manor Healthcare Center store my submitted information so they can respond to my application