APPLICATION FOR EMPLOYMENT
St. Luke's Lutheran Care Center is an Equal Opportunity Program. In accordance with Federal Law and US Department of Agriculture policy, as well as State Law, this institution is prohibited from discrimination on the basis of race, color, national origin, sex, age or disability. (Not all prohibited bases apply to all programs.)

To file a complaint of discrimination, write USDA Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue SW, Washington DC 20250-9410 or call (800) 795-2372 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

Applicant Information
 First Name  Last Name  Today’s Date
 * Please indicate any other names which you could be identified by previous employers or educational institutions    
 Street Address  City  State  ZIP
 Email (Note: application received confirmation notices will only be sent via email)
   
 Telephone Number  Alternative Number    
 Position Applied For:
Other  
 Preferred Shift:
 Number of hours desired per week:
Availability: (check all that apply)  Full Time:  Part Time:  Casual:  Seasonal:  Weekends Only: 
 Date available for employment:
 Are you unable to work on certain days?
 * If yes, please specify what days:
 Have you ever been employed at St. Luke’s before?
* If yes, final year of employment:
Do you have a legal right to be in employed in the U.S.?
Are you of legal age to work?
 

EDUCATIONAL BACKGROUND
School/City/State
Did you graduate? Course of Study:
Type of degree, if applicable

School/City/State
Did you graduate? Course of Study:
Type of degree, if applicable

School/City/State
Did you graduate? Course of Study:
Type of degree, if applicable

PROFESSIONAL REFERENCES
(List below three persons, not related to you, that have knowledge of your work performance. Examples include previous employers, co-workers, teachers or coaches.)
Name:  Phone Number:
Name:  Phone Number:
Name:  Phone Number:

PREVIOUS EMPLOYMENT (please list most recent employer first)
Company Name:  Position:  Contact Person:
Phone Number:    May we contact?  YES    
Dates of Employment:   to 
Reason for Leaving:
Company Name:  Position:  Contact Person:
Phone Number:    May we contact?  YES
Dates of Employment:   to 
Reason for Leaving:
Company Name:  Position:  Contact Person:
Phone Number:    May we contact?  YES
Dates of Employment:   to 
Reason for Leaving:
 

PLEASE READ CAREFULLY AND SIGN BELOW.
Conditions of Consideration For Employment

I hereby authorize investigation of all statements contained in this application.  I release St. Luke’s Lutheran Care Center from any and all liability resulting from such investigation.  I affirm that all information contained in this application is true and complete and that any misrepresentation, falsification, or willful omission herein shall be sufficient reason for dismissal and/or refusal of employment. 

I understand that employment is subject to satisfactory reference reports, satisfactory completion of a post-offer/background check, proof of identity and authorization to work in the United States. I authorize St. Luke’s Lutheran Care Center to contact references listed above.

I understand that employment at St. Luke’s Lutheran Care Center is “at will” employment and may be terminated at any time by either party.  I further understand that I am required to abide by all rules and regulations of St. Luke’s Lutheran Care Center.  I understand this application will be active for a period of 6 months; after that time, if I wish to be considered for employment, I must submit a new application.

I certify the information provided above is true and complete to the best of my knowledge.  I have read and understand the statements in the paragraphs above.  By signing here, I am also verifying all information on my resume.



MY TYPED NAME BELOW SHALL HAVE THE SAME FORCE AND EFFECT AS MY WRITTEN SIGNATURE.
Applicant Name    Today's Date: