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Employment Application

Step 1 of 5 – Desired Position & Personal Information

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Application for Employment

We are an Equal Opportunity Employer and committed to excellence through diversity. This application must be fully completed to be considered. Please complete each section, even if you attach a resume.
Position Applied For*
Employment Desired*
- Full time
- Part time
- Flex
Shift Desired (Nursing Only)*
- Day
- PM
- Overnight
Desired Pay
Available Start Date

MM slash DD slash YYYY
Are you vaccinated against COVID-19?*
Healthcare facilities that participate in Medicare and Medicaid programs are mandated to require all staff have been fully vaccinated against COVID-19 or have a valid medical or religious exemption.
- Yes
- No
- I have a Valid Medical or Religious Exemption
- I am not vaccinated but am willing to be vaccinated to obtain employment
PERSONAL INFORMATION
First Name*
Middle Name
Last Name*
Address*

Street Address

City

State

ZIP Code
Current Phone Number*
Email*
Are you legally eligible to work in the United States?*
- Yes
- No
If selected for employment, are you willing to submit a background check?*
- Yes
- No
Are you a veteran?*
- Yes
- No
Military Branch
Induction Date
Discharge Date

EDUCATION
Most Recent School Attended
School Name*
City & State
Phone
Dates Attended
Study Area or Major
Degree Earned?
- Yes
- No
Degree Type
Next School Attended
School Name
City & State
Phone
Dates Attended
Study Area or Major
Degree Earned
- Yes
- No
Degree Type

RECORD OF EMPLOYMENT

Please start with your current or most recent employer(s).
Employer
Current or Previous?
- Current
- Previous
Company
Job Title
Address

Street Address

City

State
Phone
Supervisor Name & Title
Employment Start Date

MM slash DD slash YYYY
Employment End Date

MM slash DD slash YYYY
Reason For Leaving
Employer
Current or Previous?
- Current
- Previous
Company
Job Title
Address

Street Address

City

State
Phone
Supervisor Name & Title
Employment Start Date

MM slash DD slash YYYY
Employment End Date

MM slash DD slash YYYY
Reason For Leaving
Employer
Current or Previous?
- Current
- Previous
Company
Job Title
Address

Street Address

City

State
Phone
Supervisor Name & Title
Employment Start Date

MM slash DD slash YYYY
Employment End Date

MM slash DD slash YYYY
Reason For Leaving
ADDITIONAL INFORMATION
Have you ever been fired or asked to resign from ANY job for any reason?*
- Yes
- No
If yes, where, when, and why?

REFERENCES

List 3 references who are present or former business associates (No relatives)
Reference 1*

Name, Phone Number, Company, and Title (separate by comma)
Reference 2*

Name, Phone Number, Company, and Title (separate by comma)
Reference 3*

Name, Phone Number, Company, and Title (separate by comma)
Were you referred by a current employee of North Star Manor? If yes, please enter their name.*
How did you hear about this position?
RESUME
Resume/Cover Letter
Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 50 MB, Max. files: 2.

SIGNATURE
I affirm that the information I have provided in this application is true to the best of my knowledge, information and belief, and I have not knowingly withheld any information requested. I understand that withholding or misstating any information requested in this application is grounds for rejection of my application, and that providing false or misleading information in this application is grounds for discharge.
I authorize the company to verify my references, record of employment, education record, and any other information I have provided. Unless otherwise noted, I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the company, my former employers and all other persons and entities, from any and all claims, demands or liabilities arising out of or in any way related to such inquiry or disclosure.
Signature*
Applicant's Name*
Date Completed*

MM slash DD slash YYYY
Post Excerpt
Phone

This field is for validation purposes and should be left unchanged.

North Star Manor provides comfort, community and peace of mind in Warren, Minnesota.
For more information, contact us today.

Long Term Care & Senior Housing Apartments: (218) 745-5282
Address: 410 S. McKinley St. Warren, MN 56762

Assisted Living: (218) 745-4125
Address: 400 S. McKinley St. Warren, MN 56762

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