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Employment Application

This employer does not discriminate in its hiring decisions or in any other employment decision on the basis of race, color, sex, religion, citizenship, national origin, veteran status, age or upon a physical or mental disability which is unrelated to the applicant's/employee's ability to perform the essential functions of the position.

    Application Cover Page

Thank you for expressing interest in employment opportunities with us. For further consideration, we need for you to complete the following application for employment so that we can gain a better understanding of your experience, skills, and availability. Please review and complete each section of the application carefully as we make initial qualifying decisions based on the responses you provide.

Applicant Name
Phone
Email
Is there any schedule or day that you are unavailable to work? Yes No
If yes, when are you unavailable to work?
What position are you interested in?
How did you hear about this position? Print Publication
Website
Referral

1. Personal Information

Date of Application
Date Available to Start Work
Name (Last First Middle)
Social Security Number
List any other names you have worked under, such as maiden name
Present Address
City
State
ZIP
Permanant Address (if different than present address)
City
State
ZIP
Telephone Number
Date of Birth
Sex Male Female
Race
Emergency Contact Person
Emergency Contact Address
Emergency Contact Number

2. Employment Desired

Position applied for
Salary required
Hours Available to Work Days
Evenings
Nights
Weekends
Will you accept employment of (check all that apply) Full Time
Part Time
Occasional Part Time

3. U.S. Military Record

Branch
Date Entered
Date Discharged
Type of Discharge

4. Prior Work History

List your last four (4) jobs beginning with your most recent or current employer.

Employer's Name
Telephone Number
Employer's Address
City
State
ZIP
Position Held
Supervisor
Date Employed From
Date Employed To
Salary
Reason for Leaving
Employer's Name
Telephone Number
Employer's Address
City
State
ZIP
Position Held
Supervisor
Date Employed From
Date Employed To
Salary
Reason for Leaving
Employer's Name
Telephone Number
Employer's Address
City
State
ZIP
Position Held
Supervisor
Date Employed From
Date Employed To
Salary
Reason for Leaving
Employer's Name
Telephone Number
Employer's Address
City
State
ZIP
Position Held
Supervisor
Date Employed From
Date Employed To
Salary
Reason for Leaving
List Name(s) of other employers for the last five (5) years
May we contact your present employer? Yes No Not Applicable
Have you ever been terminated or asked to resign from any position? Yes No
If yes, provide reason

5. Education Background

List all educational schools attended with degrees, diplomas or certificates received.

Name of Institution (High School, Technical School, College)
Type of Studies
Dates Attended & Diplomas, etc.
Name of Institution
Type of Studies
Dates Attended & Diplomas, etc.
Name of Institution
Type of Studies
Dates Attended & Diplomas, etc.
If your school or employment records are under another name(s), indicate that name(s):

6. Certification

If you hold a current certification as a nurse aide (CNA), check the appropriate certification(s) below: Long Term Care (LTC)
Home Health Aide (HHA)
Adult Day Care (ADC)
Residential Care Aide (RCA)
Developmental Disability Aide (DDA)
Certified Medication Aide (CMA)
Certified Medication Aide-Gastrostomy (CMA-G)
Certified Medication Aide-Glucose Monitoring (CMA-GM)
Certified Medication Aide-Respiratory (CMA-R)
Certified Medication Aide-Insulin Administration (CMA-IA)
List all technical special skills or education honors, certificates, licenses, memberships or Medication Administration Technician (MAT) certification not previously listed:
If you are a CMA, have you obtained your 8 hours of continuing education for the current 12-month certification period before your certification expires? Yes No
If yes, where and when did you obtain

7. References

List name, address and telephone number of three (3) references who are not relatives or former employers.

Reference 1
Reference 2
Reference 3

8. Background Information

If you answer YES to any of the questions below, explain in the space after the question. The explanation for a YES answer should include, but not be limited to:

  1. State and/or jurisdiction
  2. Nature of complaint/offense
  3. Disposition of complain and/or offense (e.g. "dismissed insufficient evidence", deferred sentence")
  4. Date of disposition
  5. Attach copy of any correspondence received by you, the applicant, regarding the complaint/offense.

Have you ever: 1) participated in a first offender program; 2) deferred adjudication or other program or arrangement where adjudication has been withheld; 3) pled guilty or no contest; 4) been convicted; 5) received a deferred sentence; and/or 6) been sentenced for any criminal offense in any state or US jurisdiction regardless of whether this matter has been expunged or otherwise removed? Yes No
Explanation
Have you ever been found in violation of any state, US jurisdiction, or federal law regulating the practice of a health care profession? Yes No
Explanation
Are any disciplinary actions or allegations, pending or substantiated, against you or your CNA certification or health care professional license in any state or U.S. jurisdiction? Yes No
Explanation
Have you had any certificate, license, registration or other privilege to practice a health care profession denied, revoked, suspended, restricted, reprimanded, censured or placed on probation by a state or US jurisdiction, federal or foreign authority or have you ever surrendered such credential to avoid, or in connection with, action by such authority? Yes No
Explanation

9. Applicant's Certification and Agreement

Please Read Carefully - If you answer 'No' to any of the questions below, explain in the space after the question.

I understand the employer has the right to proceed with any criminal background check. Yes No
Explanation
I understand as a part of the job selection process, I may be required to take a drug-screening test at the time of employment and if requested in accordance with the state and federal law at anytime during my employment. A test result that has been confirmed as positive will eliminate me from employment. If I refuse to sign this form and submit to drug testing, the employer will reject my application. Yes No
Explanation
I understand I may be required to have a physical examination and I hereby consent to take a physical examination and any future physical examinations as required by the employer. Yes No
Explanation
I understand if I am hired I will be required to produce proof that I have a legal right to work in the U.S.A. in accordance with the IRCA of 1986. Yes No
Explanation
I understand this form is not an employment contract Yes No
Explanation

10. Previous CNA Training

Complete this section ONLY if you require training

Please complete the following if you have had CNA Training in the past for any of these categories: LTC, HH, ADC, RC, or DDDC.

Category
Program Name
Start Date
End Date
Category
Program Name
Start Date
End Date
Category
Program Name
Start Date
End Date

11. Important Information for the Job Applicant

It is unlawful for any person to provide false information regarding a criminal conviction on this uniform employment application for nurse aides. Providing false information regarding a criminal conviction is a misdemeanor under Title 63 of the Oklahoma Statutes, Section 1-1950.4a. Providing false information about a criminal conviction on this application is punishable by a fine not to exceed Five Hundred Dollars ($500.00), by imprisonment in the county jail for a term of not more than one (1) year, or by both such fine and imprisonment.

*** NOTICE ***
I UNDERSTAND PROVIDING FALSE OR MISLEADING INFORMATION TO A TRAINING PROGRAM, A FACILITY, OR THE DEPARTMENT IS GROUNDS FOR DENIAL, SUSPENSION, WITHDRAWAL, AND/OR NONRENEWAL OF CERTIFICATION. I ALSO UNDERSTAND PROVIDING FALSE INFORMATION OR OMISSION OF FACTS MAY DISQUALIFY ME FROM EMPLOYMENT AND MAY CAUSE TERMINATION IF DISCOVERED AT A LATER DATE.

Initial Here

12. Criminal Arrest Check List

Effective November 1, 2012, and in accordance with public law, Title 63 of the Oklahoma Statutes, Section 1-1950.1, employment at this employer shall not be considered if the below signed individual has been convicted of, pled guilty or no contest to, or received a deferred sentence for, a felony or misdemeanor offense for any of the following offenses in any state or federal jurisdiction, as stated by Oklahoma Statute, Section 1-1950.1(C)(1) of Title 63:

a. abuse, neglect or financial exploitation of any person entrusted to the care or possession of such person,
b. rape, incest or sodomy,
c. child abuse,
d. murder or attempted murder,
e. manslaughter,
f. kidnapping,
g. aggravated assault and battery,
h. assault and battery with a dangerous weapon, or
i. arson in the first degree.

Effective November 1, 2012, and in accordance with public law, Title 63 of the Oklahoma Statutes, Section 1-1950.1, employment at this employer shall not be considered for the below signed individual if less than seven (7) years have elapsed since the completion of sentence1, and the results of a criminal history check reveal that the subject person has been convicted of, or pled guilty or no contest to, a felony or misdemeanor offense for any of the following offenses, in any state or federal jurisdiction, as stated by Oklahoma Statute, Section 1-1950.1(C)(2) of Title 63:

a. assault,
b. battery,
c. indecent exposure and indecent exhibition, except where such offense disqualifies the applicant as a registered sex offender,
d. pandering,
e. burglary in the first or second degree,
f. robbery in the first or second degree,
g. robbery or attempted robbery with a dangerous weapon, or imitation firearm,
h. arson in the second degree,
i. unlawful manufacture, distribution, prescription, or dispensing of a Schedule I through V drug as defined by the Uniform Controlled Dangerous Substances Act,
j. grand larceny, or
k. petit larceny or shoplifting.

1Pursuant to 63 O.S. § 1-1950.1(A)(5), "Completion of the sentence" means the last day of the entire term of the incarceration imposed by the sentence including any term that is deferred, suspended or subject to parole.

It is further understood that if I am hired, it will be as a temporary employee until the employer receives my criminal background check. If I have no criminal record in accordance with state law, I may be considered for employment, subject to training requirements and other requirements of the job for which I am applying with this employer.

I hereby certify I have no disqualifications for employment as described above and specified in Title 63 of the Oklahoma Statutes, Section 1-1950.1(C). My signature below authorizes the employer to run a check with the Nurse Aide Registry of the Oklahoma State Department of Health for notations of abuse, neglect or misappropriation of resident’s property. I hereby give the Oklahoma State Bureau of Investigation authority to proceed with a criminal history records check as authorized by Title 63 of the Oklahoma Statutes, Section 1- 1950.1(B).

Signature of Applicant
(please type your name)
Date of Signature

13. Pre-Screening Notice and Certification Request

Fill in the lines below and check any boxes that apply. Complete only this side.

Your Name
Social Security Number
Street Address where you live
City or Town, State, and ZIP
County
Telephone Number
If under age 40, enter day of birth

Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit.

Check here if any of the following statements apply to you.
  • I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.
  • I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.
  • I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs.
  • I am at least age 18 but not age 40 or older and I am a member of a family that: a Received SNAP benefits (food stamps) for the past 6 months, or b Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.
  • During the past year, I was convicted of a felony or released from prison for a felony.
  • I received supplemental security income (SSI) benefits for any month ending during the past 60 days.
  • I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.

Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year.

Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or released from active duty in the U.S. Armed Forces during the past year.

Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year.

Check here if you are a member of a family that:
  • Received TANF payments for at least the past 18 months, or
  • Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning after August 5, 1997, ended during the past 2 years, or
  • Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.

14. Background Authorization Statement

All applicants for employment: Please read carefully before signing below

As part of its employment application process, I understand that the company may obtain investigative consumer reports concerning my prior employment, military record, education, credit worthiness, character, general reputation, personal characteristics, or criminal background. This establishment is required by the Nursing Home Care Act to obtain a criminal history background record before making an offer of employment or contract.

By signing below, I authorize the company to obtain a consumer/investigative report on me and to check references as part of its pre-employment background investigation process. If I am offered employment by the company I further authorize the company to obtain additional consumer/investigative reports on me for employment purposes at any time during my employment. If hired, as a condition of employment, I agree to notify the employer of any change in the status of my criminal record in the event of an arrest or conviction.

Additionally, with my signature below I attest that I will hold harmless any and all of the past employers and personal references listed on my application and/or resume from any liability for providing a reference regarding my prior employment, military record, education, credit worthiness, character, general reputation, personal characteristics, or criminal background which they may be aware of.

Name of Applicant
(please type your name)
Date of Signature

I certify I have read and completed this application and that the information I have provided on this application is true and complete

Signature of Applicant
(please type your name)
Date of Signature
Attach Resume
(.doc, .docx, .pdf, .rtf)