Oglala Sioux Lakota Nursing Home

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Activities Aide

Rushville, NE, United States of America

FT

Activities

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First Name(s) *

Last Name *

Email Address *

Phone Number *

Personal Information

Mailing Address *

Physical Address *

Secondary Phone

Other Contact Number

Are you a US citizen? *If no, please provide documentation

Yes

No

Employment Desired

Type of Work Desired

Administration

Dietary

Activites

Housekeeping

Nursing

Other:

If Nursing, please Specify

Education/Training

Highest Completed Level of Education *

GED

High School

College

Name and Address of School *

Courses Taken *

Did you graduate? *

Yes

No

Diploma, Degree or certificate received *

Other Degrees/Training/Classes

Are you claiming Tribal Preference? *

Yes

No

If yes, with which tribe?

IF you claim tribal preference for the hiring process, additional documentation of tribal enrollment WILL be required.

Relevant Extra Curricular Activities while in school

Area of specialization or major interest

Professional organization membership, honors received, volunteer or community service, specialized training, or other qualifications you have which you feel are related to the position for which you are applying:

Professional Licenses and/or Certifications

Type

Organization or State Issued

Number

Date Issued

Active

Yes

No

Type

Organization or State Issued

Number

Date Issued

Active

Yes

No

Military Record

Branch

Entry Rank

Separation Rank

Separation Date

Military Occupation/Speciality

Employment History - References

List current (or most recent) employer first and all others in reverse chronological order. Please List 1) Company Name, Address, 2) Position, 3) Job Description and Responsibilities, 4) Reason for leaving, 5) Dates employed, 6) Phone Number, 7) Starting and Ending Salary, and 8) Direct Supervisor name, for each job. We will be calling these jobs for references.

Job 1:

Job 2:

Job 3:

Non-Employer References

Please list 3 references who are NOT relatives or former employers. Please list Name and relationship, title, company name and address and Phone number for each reference.

Reference 1:

Reference 2:

Reference 3:

Have you ever had any traffic violations? *

Yes

No

If yes, when and where?

Have you ever been convicted of a crime? *

Yes

No

If yes, for what, when, and where?

Have you ever been convicted of a felony and/or misdemeanor?

Yes

No

Conviction of a criminal offense will not necessarily jeopardize employment

Have you ever had disciplinary action taken against any license, registration, certificate or permit you now or previously held (This includes but is not limited to final orders, suspension, revocation, denial, cease and desist order, etc.)? *

Yes

No

If yes, please explain

How did you hear about this opportunity? *

This business does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, veteran status, sexual orientation, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give this business the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.

I understand that a criminal background check and driving record check will be conducted prior to employment.

By signing below I recognize that my digital signature is subject to all the same consequences as a physical signature. *

Date Completed *

Please upload 1 non-expired photo ID, 1 other form of ID (Social security card, etc) and a copy of a High school diploma OR GED OR College Transcripts. (If you are using a phone, please make sure all documents are in one picture.) *

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