Job Application – Certified Nursing Assistant / Memory Care Specialist

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Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone
Cell Phone
Email*
Best way to contact me
- Text
- Email
- Phone
General Information
Position applied for:
Available to work
- Full-Time
- Part-Time
- On Call
- Temporary
Shift desired
- Day
- Night
- Evening
- Any Shift
Date available to start work
MM slash DD slash YYYY
How did you hear about this position?
Do you have a legal right to work and be employed in the U.S.?
- Yes
- No
Are you at least eighteen years of age?
- Yes
- No
(Proof of age and work permits may be required prior to hiring)
Have you ever worked for the Sisters of Mercy before?
- Yes
- No
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Position
Manager

Education / Professional Affiliations
High School
Name of School and Address
Major
Number of years completed
Did you Graduate
- Yes
- No
College
Name of School and Address
Major
Number of years completed
Did you Graduate
- Yes
- No
Other (Specify)
Name of School and Address
Major
Number of years completed
Did you Graduate
- Yes
- No
Employment History
Please list your present and past work experience for the last 10 years, beginning with your current job. You may include volunteer activities.
Name of Employer
May we contact this employer?
- Yes
- No
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Address
Telephone
Position
Supervisor
Description of Duties
Reason for Leaving
Name of Employer
May we contact this employer?
- Yes
- No
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Address
Telephone
Position
Supervisor
Description of Duties
Reason for Leaving
Name of Employer
May we contact this employer?
- Yes
- No
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Address
Telephone
Position
Supervisor
Description of Duties
Reason for Leaving
Name of Employer
May we contact this employer?
- Yes
- No
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Address
Telephone
Position
Supervisor
Description of Duties
Reason for Leaving
Name of Employer
May we contact this employer?
- Yes
- No
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Address
Telephone
Position
Supervisor
Description of Duties
Reason for Leaving

Please explain below any gaps of employment in excess of three months in the last ten years. Period of Unemployment:
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Reason for unemployment
To assist us in verifying prior employment and education, please indicate whether you were ever employed or enrolled in a school under a name other than that used on this application:
yes/no
- Yes
- No
If yes, please specify the name you were employed or enrolled under and when:
Do you have any relatives/friends employed by the Sisters of Mercy?
- Yes
- No
Name
First Last
Relationship
Department
Name
First Last
Relationship
Department
Please provide the names and contact information of at least three professional references that are not related to you. Sisters of Mercy, West Midwest prefers references which have supervised or managed you.
Name
Relationship
Phone
Email
Name
Relationship
Phone
Email
Name
Relationship
Phone
Email

I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and I agree to have any of the statements checked by the Sisters of Mercy unless I have indicated to the contrary. I authorize the references listed above, as well as all other individuals whom the Sisters of Mercy contacts, to provide the Sisters of Mercy with any and all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to the Sisters of Mercy as well as from any use or disclosure of such information by the Sisters of Mercy or any of its agents, employees, or representatives. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer or, if I am hired, my immediate dismissal from employment.

In consideration of my employment, I agree to conform to the rules and standards of the Sisters of Mercy. I further agree that my employment and compensation can be terminated at will, with or without cause, and with or without notice, at any time, either at my option or at the option of the Sisters of Mercy. I understand that no employee or representative of the Sisters of Mercy, other than its Chief Operating Officer (COO), has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. Further, the COO of the Sisters of Mercy may not alter the at-will nature of the employment relationship unless the COO and I both sign a written agreement that clearly and expressly specifies the intent to do so. I agree that this constitutes an integrated agreement with respect to the at-will nature of my employment relationship, that it is final and fully binding, and that there are no oral, written, or collateral agreements regarding this issue.
I wish to waive my right to receive a copy of any public record information obtained during reference verification.
- Yes
- No
I also understand that all offers of employment are conditioned on the provision of satisfactory proof of an applicant's identity and legal authority to work in the United States, as well as the satisfactory results of employment references and background/drug screening checks.
Electronic Signature
Date
MM slash DD slash YYYY

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General Information

Education / Professional Affiliations

High School

College

Other (Specify)

Employment History