Halstad Lutheran Living Center :: Employment Application

Employment Application

First Name:

Last Name:

Street Address:

City:

State:

Zip:

Phone Number:

Are you legally eligible for employment in the USA? (If hired, you are required to submit proof or your eligibility to work in the USA):

Are you over the age of 18? (If no, hire is subject to verification that you are of minimum legal age):

Position(s) applied for:

Location:

Were you previously employed by us?

On what date will you be available for work?

Are there any other job related experiences, skills, or qualifications which will be of specialbenefit in the job for which you are applying?

High School Name & Address:

Last Year of High School completed:

Work Experience

Most Recent Employer's Company Name

Contact

Phone:

Address:

Salary:

Position:

Reason(s) for Leaving:

Employed From:

Employed To:

2nd Most Recent Employer's Company Name:

Contact

Phone:

Address:

Salary:

Position:

Reason(s) for Leaving:

Employed From:

Employed To:

3rd Most Recent Employer's Company Name:

Contact

Phone:

Address:

Salary:

Position:

Reason(s) for Leaving:

Employed From:

Employed To:

May we contact your present and previous supervisors for a reference? Yes No

References

Reference 1 Name:

Phone:

Relationship:

Address:

Reference 2 Name:

Phone:

Relationship:

Address:

May we contact your references mentioned above? Yes No

Other Info

May we telephone you to follow up on this application at home?

If yes, what is the best time to call?

Other Last Names You Have Used:

Birth Date:

Gender:

Race:

The information collected is used for background check purposes only. It is the policy of Halstad Living Center not to discriminate against any applicant for employment, or any employee because of age, color, sex, disability, national origin, race, religion, or veteran status.