Today's Date:   
Last Name:  First Name:  Middle Initial: 
Address/PO Box: City:
State: Zip Code: Telephone:
Position(s) Applied For:
Date Available:   Shift Preference:

Have you ever (1) been convicted by any court, including a court of military
justice, of a felony, or (2) been released from prison following conviction
of a felony?    Yes:    No: 

If you have any relatives that work here, please list:
 

Maiden Name:

Education

High School:      Location:   
Check Year Completed: 9:  10:  11: 12: Major:
Graduated?  Yes:    No:    Degree?

College:             Location:   
Check Year Completed: 1:   2:   3:     4: Major:
Graduated?  Yes:    No:    Degree?

Describe any specialized training, apprenticeship, skills you may have:

Personal Reference Information  (no relatives please)

Name                                  Telephone Number                Relationship
           
           
           

Employment History

Present/Last Company Name and Address:

Company Phone Number: 
Title:   
Employment dates:  From:        To: 
Last Base Rate of Pay: 
Briefly describe your duties: 
Name of Supervisor: 
Reason for Leaving (please be specific:  Quit, Layoff, Discharge, etc.)

Company Name and Address:

Company Phone Number: 
Title:   
Employment dates:  From:     To: 
Last Base Rate of Pay: 
Briefly describe your duties: 
Name of Supervisor: 
Reason for Leaving (please be specific:  Quit, Layoff, Discharge, etc.)

Company Name and Address:

Company Phone Number: 
Title:   
Employment dates:  From:      To:  
Last Base Rate of Pay: 
Briefly describe your duties: 
Name of Supervisor: 
Reason for Leaving (please be specific:  Quit, Layoff, Discharge, etc.)

If previously employed by Luther Home of Mercy, please list dates and position held:

*If hired you will be required to submit proof of authorization to work in the United States.
*Hire is subject to verification that employee’s age meets legal requirements.
*The shift, working hours or duties may be changed from time to time due to changes in management 
   policy or procedure.
*Proof of license for Licensed Nurses is required by this facility.
*A Criminal Records check will be made in accordance with Senate Bill 160.

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary
in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 60 days.  Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or 
not applications are being accepted at that time.

If I am employed, I acknowledge that there is no specified length of employment and that this application
does not constitute an agreement or contract for employment.  Accordingly, either I or the employer
can terminate the relationship at will, with or without cause, at any time, so long as there is no violation 
of applicable federal or state law. 

In the event of employment, I understand that false or misleading information on my application or
interview(s) may result in discharge.  I understand, also, that I am required to abide by all rules and
regulations of the employer.

I have read and understand the above and agree to all items stated:

YES         NO

  Applicant Survey

Thank you for your interest in Luther Home of Mercy.  Please 
take a minute to check the appropriate space.  Where did you 
hear about openings at Luther Home of Mercy?

Newspaper:  The Blade:   The Press:   News Herald:
School:   Name of School:
Church: Name of Church:
Television: WTOL Job Line: 
State Job Service:    Which County: 
Referred by Friend: 
Walk In: 

For Office Use Only

Hire Date:                            Employee #:   
Position:                      DOB:             
Rate of Pay:                            Status:            

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