Application - The Lutheran Home

Personal Information
First Name *
MIddle Initial
Last Name *
Address *
Street Address
City * State / Province / Region * Postal / Zip Code * Country

Phone Number * Email
Are you 16 years of age or older? (If not you may be required to provide authorization to work). *

Please fill this field
YES NO
Are you 18 years of age or older? *

Please fill this field
YES NO
Are there other names under which you have worked or attended school? If YES, please list
Are you legally able to work in the United States? *

Please fill this field
Yes No
Were you ever convicted of any crime anywhere, including in federal, state, local, military and tribal courts?*

Please fill this field
Yes No
Do you have any pending or have you ever been convicted of any felony, misdemeanor, or other offense, including but not limited to any criminal, municipal or local ordinance violations? If yes, complete the following

Note: A conviction record or pending arrest record does not constitute an automatic bar to employment and will be considered only if there is a substantial relationship to the circumstances of the particular position
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Position Desired
Position Title *
Do you have a CNA license?
Yes No
License Number
If you selected OTHER, please specify.
Available as of *
Available to work *

Please fill this field
Full-Time Part-Time Pool (every other weekend)
Shift Preference
1st 2nd 3rd
Desired Salary
Have you been employed at Lutheran Home and Harwood Place before? *
Please fill this field

Yes No
Position title at that time?
Where did you hear about this position for which you are applying?
If you selected OTHER, please specify.
If you selected FROM A Lutheran Home and Harwood Place EMPLOYEE OR VOLUNTEER whom may we thank? (First and last name.)
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Employment History
If currently employed, may we contact that employer?
Yes No
1. Employer
Position
Employment Start Date
Employment End Date
Address City State / Province / Region Postal / Zip Code Country
Phone Number
Supervisor
Specific Duties
Reason for Leaving

2. Employer
Position
Employment Start Date
Employment End Date
Address City State / Province / Region Postal / Zip Code Country
Phone Number
Supervisor
Specific Duties
Reason for Leaving

3. Employer
Position
Employment Start Date
Employment End Date
Address City State / Province / Region Postal / Zip Code Country
Phone Number
Supervisor
Specific Duties
Reason for Leaving

4. Employer
Position
Employment Start Date
Employment End Date
Address City State / Province / Region Postal / Zip Code Country
Phone Number
Supervisor
Specific Duties
Reason for Leaving
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Education
Current high school student *

Please fill this field
Yes No
Current grade High school name

High school diploma or equivalent received? *

Please fill this field
Yes No
High school name
Special/College/Professional

List additional Special/College/Professional information if applicable:
2year 4year Masters
Institution Name:
Location:
Major subjects?
Diploma or degree received?

Please fill this field
Yes No

Special/College/Professional

List additional Special/College/Professional information if applicable:
2year 4year Masters
Institution Name:
Location:
Major subjects?
Diploma or degree received?
Yes No
Skills and Qualifications
List any special considerations, training, certification, registration, etc. which may be important to the particular position for which you are applying. Please include professional license or certification numbers and expiration dates. CNA/CBRF
I certify that all information provided by me in support of my application for employment is true and correct to the best of my knowledge. I understand that any misrepresentations, omissions, false or evasive information, may result in denial of employment or be cause for subsequent dismissal if I am hired.

I authorize LutheranLiving Services to investigate my responses on this application and contact any or all of my former employers or any individuals familiar with me or my employment background for the purpose of verifying any information I have provided and/or for the purpose of obtaining any information, whether favorable or unfavorable, about my employment. I hereby authorize any former employer, firm, corporation, or government agency to answer any and all questions and to release or provide any information within their knowledge or records. I voluntarily and knowingly fully release and hold harmless any person or organization that provides information pertaining to me or my employment.

I understand that a job offer made to me will be contingent upon satisfactory physical examination, drug screen, employment references, and criminal background investigation.

I understand that whether or not I become employed by LutheranLiving Services, I recognize that this application is not and should not be considered a contract of employment. I also understand that employment at LutheranLiving Services is on an at-will basis and that my employment may be terminated with or without cause, for any reason or for no reason at all, with or without notice, at any time, at my option or LutheranLiving Services unless specifically provided otherwise in a written employment contract. I further understand that no company representative has the authority to enter into a contract with me regarding duration of terms and conditions of employment other than an officer of LutheranLiving Services and then only by means of a signed, written document.
I acknowledge
Feel free to attach your resume here.

You may attach a WORD document or a PDF here.
Applicant's Signature* Date *
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Personal Information

Position Desired

Employment History

Education

Special/College/Professional

Special/College/Professional

Skills and Qualifications

About Us

Harwood Place

Lutheran Home

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