Application for employment at:*Choose OneHastingsFremontNotice to applicantsThis community does not discriminate on the basis of age, gender, gender orientation, race, color or creed, religion, ancestry, national origin, genetics or disability other than those related to the ability to perform the job for which the applicant is being considered, or any other legally protected status. After a conditional job offer is extended, Nebraska law requires the community to perform a criminal background, sex offender, and registry checks on all direct care staff. It is the policy of this community to not hire direct care staff with criminal histories involving violence, abuse, neglect, or misuse of others’ property. State law requires every staff person to complete a health history screen. This application is current for ninety (90) days. If the applicant does not hear from this community in ninety (90) days and still desires to be considered for employment, it will be necessary to complete a new application. Dishonesty in completing this form is reason for immediate dismissal.Applicants InformationName* First Middle Last Current Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Position Applied For:* Hours Desired* Day Evening Night Work Desired* Full time Part time Temporary Desired Wage:*Wage Type* Hourly Salary Have you previously worked for this community? Yes No Dates Referral Source:* Are you over 18 years of age?* Yes No Have you ever been convicted of a felony or misdemeanor?* Yes No List any convictions and dates:Employment HistoryCurrent Employer* Dates Employed* Address* Phone*Position/Title* Name and Title of Supervisor* Summary of Duties*Reason for Leaving* Starting Wage*Current Wage*Previous Employer* Dates Employed* Address* Phone*Position/Title* Name and Title of Supervisor* Summary of Duties*Reason for Leaving* Starting Wage*Current Wage*Training & EducationHighest grade completed: Degree/diploma: Other training: Licenses/certification held: Honors/extracurricular activities during school: Other professional organizations, honors, and community involvement you feel contributes to your job qualifications:Personal References:*NamePhoneEmailRelationship Must include: 2 former supervisors, 2 former co-workers, 2 former residents and/or family members of residents for whom you’ve provided care. We ask that you contact these individuals and let them know we will be calling to speak with them.Employment Agreement:* I agree to the followingI give this community permission to contact previous employers and personal references and release from all liability all individuals or companies providing such information. I understand my employment and/or continued employment may be dependent upon the results of background checks. I understand my employment may be terminated for any dishonesty in completing this form.