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Employment Form

Step 1 of 4

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Application for Employment
We are an EEO / AA Employer
Name
First*
Middle*
Last*
Date of Application*
Present Address
Address*
Street Address City State ZIP Code
Home Phone*
Cell Phone
Email*
Enter Email Confirm Email
Emergency Contact
Name
Relationship
Phone
Position Applying for
- RN
- LPN
- PT / OT / ST
- Home Health Aide
- Homemaker
- Companion
- Office / Administrative
Type of Position Desired:
- Full Time
- Part Time
- Backup
Shift Preference*
- Day
- Evening
- Night
- Weekend
- Any
Are you willing to commute?*
- Yes
- No
If yes, how far?
Salary Desired*
Date Available*
Were you referred by a current Hiawatha HomeCare employee? If so, please indicate
Have you previously been employed by Hiawatha HomeCare?*
- Yes
- No
If yes when?
Are you currently subject to a non - compete/non - solicitation agreement?*
- Yes
- No
If yes, list employer name and date of agreement:
Are you at least 18 years of age? (If no, you may be required to provide proof to work)*
- Yes
- No
Are you eligible for employment in the U.S.?*
- Yes
- No
As required by law, employment is contingent upon your ability to provide documented proof of citizenship or legal eligibility within 3 business days after hire.

EMPLOYMENT EXPERIENCE
In order that we may verify prior experience, have you used another name in your previous jobs?*
- Yes
- No
List other names used
1.
Complete in order with most recent employer first.
Name
Date From
Date To
Address
Street Address City State ZIP Code
Phone
Salary / Hourly Rate
Supervisor
Position Held
Reason for leaving
Can we contact as a reference
- Before job offer is made
- After job offer is made
- Please do not contact
Could you be rehired for the position you last held?
- Yes
- No
2.
Name
Date From
Date To
Address
Street Address City State ZIP Code
Phone
Salary / Hourly Rate
Supervisor
Position Held
Reason for leaving
Can we contact as a reference
- Before job offer is made
- After job offer is made
- Please do not contact
Could you be rehired for the position you last held?
- Yes
- No
3.
Name
Date From
Date To
Address
Street Address City State ZIP Code
Phone
Salary / Hourly Rate
Supervisor
Position Held
Reason for leaving
Can we contact as a reference
- Before job offer is made
- After job offer is made
- Please do not contact
Could you be rehired for the position you last held?
- Yes
- No

Professional References
1. Name
Phone
2. Name
Phone
3. Name
Phone
PLEASE READ BEFORE SIGNING
1. I certify that all answers and statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing which, if disclosed, might affect this application unfavorably. I understand that any falsification, misrepresentation or material omission of information submitted on this application will constitute grounds for denial or immediate dismissal from employment if I am hired.

2. I hereby authorize investigation of all statements contained herein and employers listed above to give you any and all information concerning my employment, and any pertinent information they may have, and release all parties from all liability for any damage that may result from furnishing same.

3. I understand that Hiawatha HomeCare has a policy of at will employment where the employment relationship may be terminated without notice or cause by either myself or Hiawatha HomeCare.

4. If accepted for employment I agree to comply with all company policies and procedures, and to perform all duties assigned to me to the best of my ability.

5. This application is current and active for 1 year. At the conclusion of this time, if I have not had any contact from Hiawatha HomeCare and still wish to be considered for employment, it will be necessary for me to complete a new employment application.
I Agree to the Above*
- Agree
Signature*
Date of submission*
Name
This field is for validation purposes and should be left unchanged.

Hiawatha Homecare
4920 Moundview Drive, Suite B
Red Wing, MN 55066

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Phone: 1-651-388-2223
Toll Free: 1-800-837-8898
Fax: 1-651-388-2227

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