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Application For Employment



We consider applicants for all positions without regard to race, color, religon, creed, gender, national origin, age, disability, or any other legally protected status.
Incomplete applications will not be considered for employment.

 

____________________________________________________________________________
Position(s) applied for
Type of employment desired:
Shifts Available:
If currently employed, may we contact your employer?
Is there a specific reason you are appling for employment at this company?
If Yes, please briefly outline the reason:
Are you eligible for employment in USA?
Are you available for overtime if required?
Have you ever applied to Prairie Home Elder Services before?
Do you have any friends or family employed at this location?
Have you ever been convicted of a crime in the last seven (7) years?
If considered for hiring, will you agree to a criminal background check?
If considered for hiring, will you agree to take TB skin test?  
_________________________________________________________________________

EDUCATIONAL BACKGROUND
List previous three (3) educational institutions attended, beginning with the most recent.

School City, State Graduated? Degree(s) /Diploma(s) earned
 What Nursing or revelant designations, licenses or registrations if any, do you possess?
Type Date of Most Recent Registration Vaild in State of Wisconsin?
Do you have the following?
CPR
First Aid
Med. Administration
Fire Safety
PLEASE ANSWER THE FOLLOWING QUESTIONS

What do you think is the most difficult part of caregiving work?

What was the best/least favorite job you ever had and why?

Think of the best supervisor you have ever had, what characteristics made that person a good manager?

List some examples of the positive and negitive aspects of growing old.

Serveral kinds of confusion in elderly require much individual time and patience. Please give an example of how you were able to show great patience and another when you were not.

How are you able to contribute to providing seniors with high quality care?

How would you handle the following situation: Mrs. Anderson has intentionally dropped her drink on the living room rug, and then yelled, "There! Now clean it up!" Why did she do this? How would you handle it?

________________________________________________________________
EMPLOYMENT BACKGROUND
Provide the  following information beginning with the most recent employer.
Dates Employed
SUMMARIZE THE TYPE
OF WORK
PERFORMED AND JOB DUTIES
From To
Hourly: Rate/Salary
Starting
Hourly: Rate/Salary
Ending
May we contact references?
Dates Employed
SUMMARIZE THE TYPE
OF WORK
PERFORMED AND JOB DUTIES
From To
Hourly: Rate/Salary
Starting
Hourly: Rate/Salary
Ending
May we contact references?
Dates Employed
SUMMARIZE THE TYPE
OF WORK
PERFORMED AND JOB DUTIES
From To
Hourly: Rate/Salary
Starting
Hourly: Rate/Salary
Ending
May we contact references?
Dates Employed
SUMMARIZE THE TYPE
OF WORK
PERFORMED AND JOB DUTIES
From To
Hourly: Rate/Salary
Starting
Hourly: Rate/Salary
Ending
May we contact references?
REFERENCES
List the name, relationship, number of years acquainted, phone number of three references, (No relatives please).
Name Relationship Years Acquainted Phone

APPLICANT'S STAEMENT
I certify that all the information I have provided is true and complete to the best of my knowledge.

I authorize the investigation of all statements contained in this application for the employment, my references, and an independent investigation of my character, conduct and employment records.

This application for employment shall be considered active for a period of time not to exceed 1 year. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at this time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with Prairie Home Elder Services, LLC is of an “at will” nature, which means that the Employee may resign at any time and the Prairie Home Elder Services, LLC may discharge the Employee at any time with or with out cause. It is further understood that this “at will” employment relationship may not be charged by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of Prairie Home Elder Services, LLC.

I further agree that failure to reveal any prior employer or giving false or misleading information in my application for employment or during any interview will be grounds for termination of employment. I understand, also, that I am required to abide by all the rules and regulations of Prairie Home Elder Services, LLC.

I understand that if I am hired, I will be required to provide criminal background check, proof of identity and legal authority to work is the USA, proof of certifications or educational qualifications, and drivers abstract (if applicable).

Applicant’s Signature Date

 
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