Southview Senior Communities

Employment Application

Personal Information

First Name: *

Last Name: *

Phone with area code: *

Email Address: *

Position: *

Street Address: *

City: *

State/Province: *

ZIP: *

Have you ever applied for employment with us?

yes no

If yes month & year

Apart from absence for religious observance, are you available for full time work?

yes no

If yes month & year

Social Security Number #

Would you work overtime?

yes no

When would you be available to begin?

Are you prevented from lawfully becoming employed in this country because of visa or immigration status? *

yes no

Education

Highest Level

High School Diploma or Equivalent:

yes no

College Diploma or Equivalent:

yes no

Number of Years of Higher Education:

Certifications or Degrees Achieved:

EMPLOYMENT HISTORY - List present or most recent employer first

No previous employment history

1. Company Name:*

Telephone:*

Street Address:*

Date Employed:*

City, State and Zip Code:*

Positions:*

Rate of Pay:*

Start

End

Contact Person or Supervisor:*

Primary Responsibilities:*

Reason for leaving:*

2. Company Name:

Telephone:

Street Address:

Date Employed:

City, State and Zip Code:

Rate of Pay:

Start

End

Contact Person or Supervisor:

Primary Responsibilities:

Reason for leaving :

Positions :

3. Company Name:

Telephone:

Street Address:

Date Employed:

City, State and Zip Code:

Rate of Pay:

Start

End

Contact Person or Supervisor:

Primary Responsibilities:

Reason for leaving :

Positions :

Document Attachments (file types accepted are .doc, .docx, & .pdf - up to 2MB)

Upload Resume:

Optional Application Survey

OPTIONAL APPLICATION SURVEY

As part of Southview Senior Communities Affirmative Action Program and its compilation of data for equal employment opportunity reporting requirements, we are required to collect statistical information about the ethnic/sex/disability composition of its job applicants to various governmental agencies. In order to accurately report its applicant statistics, Southview Senior Communities is requesting your assistance in providing the information requested by completing the following survey.

THIS SURVEY IS CONFIDENTIAL AND IS FOR REPORTING PURPOSES ONLY. IT WILL NOT BE USED TO MAKE A DECISION ON WHETHER TO HIRE YOU. THIS SURVEY IS NOT PART OF YOUR APPLICATION AND IS MAINTAINED AS A SEPARATE DOCUMENT BY SOUTHVIEW SENIOR COMMUNITIES EEO COMPLIANCE OFFICER.

This information is strictly voluntary.

THANK YOU FOR YOUR COOPERATION!

1. Type of job applied for:

Home Health Aide

Housekeeper

Dietary Server

Activity Director

Cook

2. Gender:

Male Female

3. Race:

American Indian/Native Alaskan Asian Black Hispanic Native Hawaiian or Other
Pacific Islander Caucasian More than one race

4. Disability

A disability is defined as a "physical or mental impairment that substantially limits a major life activity." This means major life activities such as walking, seeing, hearing, speaking, breathing, learning and working.
If you perceive yourself to have a disability please check "Yes" and specify the disability. If you do not perceive yourself to have a disability, check "No."

If Yes, please specify:

No, I do not perceive myself as having a disability

5. How did you hear about employment with Southview Senior Communities?

Walk-in

Internal Posting

Employee Referral - Employee Name:

Advertisement - Name of Publication:

Employment Agency - Name of Agency:

Website/Online:

Other - Source:

Background Check and References

References - List below three persons not related to you, whom you have known at least one year.

* If you are hired by this company, you will be required to attest to your identity and employment eligibility, and provide documents confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements. Authorization – I certify that the facts contained in this application and accompanying resume are true and complete to the best of my knowledge. I understand that any false statements, omission, or misrepresentation on this application is sufficient cause for refusal to hire or dismissal if I have been employed on matter when discovered by the company. I understand that my employment is conditional on a background check. I authorize the company to thoroughly investigate all statements contained in myapplication or resume and I authorize my former employers and references to disclose information regarding my former employment, character, and general reputation to the company without giving me prior notice of such disclosure. In addition, I release the company, any former employers and all references listed above from any and all claims, demands or liabilities arising out of or related to such investigation or disclosure. I understand and agree that if I am hired, my employment will be "at will" and without fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or the company.

Authorization to release information Minnesota background checks

Last Name *

First Name *

Middle Name * (If None, please enter NA)

MN Driver's License # or MN State ID #*

Date of Birth (month, date, year) *

Social Security # (9 digits) *

Gender * M F

Race (Optional)

Current Street Address *

Phone Number *

City *

State *

Zip code *

Other last names I have used * (If None, please enter NA)

* I authorize the release of any and all information to Southview Senior Communities in their background verification of my criminal history. The Minnesota Department of Human Services, Licensing Division is authorized to release to Southview Senior Communities or its agents any personal information about me relative to the conviction, guilty plea, or nolo contender plea of any crime. I further understand and waive my rights of privacy in this release of information and hold harmless Southview Senior Communities and its agents from any liability in this background investigation. I agree that if any misrepresentation has been made by me herein, or the results of such investigation are not satisfactory, any offer of employment made may be withdrawn, or my employment terminated immediately. This authorization expires one year from this date.

Terms and Conditions

Terms and Conditions

If you are hired by this company, you will be required to attest to your identity and employment eligibility, and provide documents confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements. Authorization – I certify that the facts contained in this application and accompanying resume are true and complete to the best of my knowledge. I understand that any false statements, omission, or misrepresentation on this application is sufficient cause for refusal to hire or dismissal if I have been employed on matter when discovered by the company. I understand that my employment is conditional on a background check. I authorize the company to thoroughly investigate all statements contained in myapplication or resume and I authorize my former employers and references to disclose information regarding my former employment, character, and general reputation to the company without giving me prior notice of such disclosure. In addition, I release the company, any former employers and all references listed above from any and all claims, demands or liabilities arising out of or related to such investigation or disclosure. I understand and agree that if I am hired, my employment will be "at will" and without fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or the company.

I authorize the release of any and all information to Southview Senior Communities in their background verification of my criminal history. The Minnesota Department of Human Services, Licensing Division is authorized to release to Southview Senior Communities or its agents any personal information about me relative to the conviction, guilty plea, or nolo contender plea of any crime. I further understand and waive my rights of privacy in this release of information and hold harmless Southview Senior Communities and its agents from any liability in this background investigation. I agree that if any misrepresentation has been made by me herein, or the results of such investigation are not satisfactory, any offer of employment made may be withdrawn, or my employment terminated immediately. This authorization expires one year from this date.

SUPPLEMENTAL NURSING SERVICES AGENCIES, EDUCATIONAL PROGRAMS, TEMPORARY EMPLOYMENT AGENCIES, PROFESSIONAL SERVICES AGENCIES

Background Study Privacy Notice

Because the Minnesota Department of Human Services is requesting that you provide private information about yourself, the Minnesota Government Data Practices Act requires that you be informed of the following:

1. Purpose and intended use of the information: Minnesota Statutes, section 144.057, requires the Minnesota Department of Human Services (DHS) to conduct background studies on individuals who have direct contact with patients and residents in hospitals, boarding care homes, outpatient surgical centers, nursing homes, home care agencies, residential care homes, board and lodging establishments registered to provide supportive or health supervision services, individuals employed by supplemental nursing services agencies, and controlling persons of a supplemental nursing services agency; and all other employees in nursing homes. The background studies are to be completed according to the requirements in Minnesota Statutes, chapter 245C. The information requested will be used to perform a background study of you that will include at least a review of criminal conviction records held by the Minnesota Bureau of Criminal Apprehension and records of substantiated maltreatment of vulnerable adults and children. DHS may also later require you to submit additional information and/or your fingerprints if necessary to complete your background study. For all individuals who are subject to background studies by DHS, the corrections system will report new criminal convictions for disqualifying crimes to DHS. County agencies and the Minnesota Department of Health report substantiated findings of maltreatment of minors and vulnerable adults to DHS.

2. Whether you may refuse or are legally required to provide the information: Minnesota Statutes, chapter 245C, states that the individual who is the subject of a study must provide sufficient information to ensure an accurate background study.

3. Known consequences that may arise from supplying the information: Individuals who have histories with the characteristics identified in Minnesota Statutes, chapter 245C, will be disqualified from positions allowing direct contact with (and, where applicable, access to) persons receiving services. Healthrelated licensing boards will make a determination whether to impose disciplinary or corrective action on individuals regulated by health-related licensing boards who have been determined to be responsible for substantiated maltreatment. Individuals who do not have disqualifying characteristics will not be disqualified.

4. Known consequences that will arise from refusing to supply the requested information: Only items identified as "optional" may be left blank. Refusal to provide the information necessary to ensure an accurate and complete background study will result in your disqualification and an order to the agency or facility to remove you from any position allowing direct contact with (and, where applicable, access to) persons receiving services.

5. Identification of other agencies or entities authorized to receive this information: The information you provide will be shared with the Minnesota Bureau of Criminal Apprehension. If DHS has reasonable cause to believe that other agencies may have information pertinent to a disqualification, the information may also be shared with county attorneys, county sheriffs, courts, county agencies, local police, the Federal Bureau of Investigation, the Office of the Attorney General, agencies with criminal record information systems in other states, and juvenile courts. Background study results may be shared with the Minnesota Department of Health, the Minnesota Department of Corrections, Office of the Attorney General, non-licensed personal care provider organizations, and health-related licensing boards. If you have a disqualifying characteristic, the facility will be told only that you are disqualified and will not be told what caused your disqualification, unless you were disqualified for refusing to cooperate with the background study or for serious and/or recurring maltreatment of a minor or vulnerable adult. The information about you received as part of a background study is classified as private data and, except for the agencies noted, cannot be shared without your consent.

* Yes, I have read the background study privacy notice.

E-mail address (You will be e-mailed a notice that your application has been received.)

** Some confirmation emails may end up in the spam folder

By checking the box below I signify I have read the statements above and at the top of this application.
* I accept the terms and conditions

Signature

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Dietary Server

Job Description

Job Location

Duties and Responsibilities

Qualifications

Employment Application

Optional Application Survey

Background Check and References

Terms and Conditions

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