Application for Employment Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. – Step 1 of 9Personal InformationName *FirstLastAddress *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email * Center? applying Date Date of Birth *NextDepartment *NursingDietaryAssisted LivingOtherChoose to open specific jobs. Then select from the dropdown.Nursing Jobs *RNLPNCNACMTNA/CaregiverDietary Jobs *CookDietary AideKitchen AideAssisted Living Jobs *LIMA1AideKitchen AideOther Jobs *LaundryHousekeepingActivity AideMaintenance AideAre you applying for: *Full TimePart TimeCasualShift Preference *DayEveningsOvernightWould you consider working any shift?YesNoAre you currently employed? *YesNoAre you available to workRotating WeekendsSome HolidaysDate available to start work:Referral Source:Morningside Center StaffAdvertisementFriend/RelativeEmployment AgencyOtherMorningside Center Staff Referral *Advertisement Source *BillboardFacebookIndeedRadioWebsiteFast LanesNewspaperNextHave you ever been employed by Morningside Center? *YesNoIf yes, please explain *Do you have any relatives that work or have worked for Morningside Center? *YesNoIf yes, please explain and include department *Are you a U.S. Citizen or an alien legally authorized to work in the United States?YesNoNextEducationHigh School or Equivalent School Name and LocationYears CompletedDid you Graduate?Diploma / DegreeUndergraduate College/University School Name and LocationYears CompletedDid you Graduate?Diploma / DegreeCourse of StudyGraduate/Professional School Name and LocationYears CompletedDid you Graduate?Diploma / DegreeCourse of StudyAre you currently enrolled in school? *YesNoIf yes, where: *High SchoolCollegeSkills and QualificationsSummarize any training, skills, licenses, and/or certificates that may qualify you as being able to perform job related functions in the position for which you are applying.Current LicensesRegistered NurseLicensed Practical NurseChoice 3License NumberCurrent CertificationsCMTCNALIMA1Certification NumberIs Your CPR Card CurrentYesNoNextEmployment Experience (most recent first)Employer 1 Name of EmployerDate Employed From/ToEmployer Phone NumberEmployer AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSupervisorTitleDutiesReason for LeavingMay we contact this employer?YesNoIf no, please explain:Employer 2 Name of EmployerDate Employed From/ToEmployer Phone NumberEmployer AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSupervisorTitleDutiesReason for LeavingMay we contact this employer?YesNoIf no, please explain:Employer 3 Name of EmployerDate Employed From/ToEmployer Phone NumberEmployer AddressAddress Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSupervisorTitleDutiesReason for LeavingMay we contact this employer?YesNoIf no, please explain:NextReferencesList 3 personal references who are not related. NameRelationship/TitlePhone *NameRelationship/TitlePhone *NameRelationship/TitlePhone *Signature of Applicant *I agree the information provided in the application is true, correct and complete. If employed, any misstatement or omission of fact on this application may result in my dismissal. I give the employer the right to contact and obtain information from all references, employers, educational institutions and to otherwise verify the accuracy of the information contained in this application. I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future.In order to permit Morningside Center Nursing Home and Assisted Living Apartments to make a thorough investigation of my background, criminal record (adult or juvenile), health, family, personal habits and reputation for employment with said entity, I hereby release from liability and promise to hold harmless from any liability under any and all possible causes of legal action any and all persons who shall furnish any information or opinions regarding my background, criminal record (adult or juvenile), health, family, personal habits or reputation. The undersigned hereby authorizes any person or legal entity who may be contacted by Morningside Center Nursing Home and Assisted Living Apartments, its officers, agents, or employees to release and transmit to such officers, agents or employees, any information, data, or opinions they may have regarding my background, criminal record (adult or juvenile) health, family, personal entities contacted by Morningside Center Nursing Home and Assisted Living Apartments any and all legal privileges I may have to maintain such information as confidential, including but not limited to the following privileges: Attorney-client, physician-patient, psychotherapist-patient, clergyman-penitent, husband-wife, and accountant-client. The undersigned further agrees to hold harmless and release from liability under any and all possible causes of legal action Morningside Center Nursing Home and Assisted Living Apartments, the Livingston County Nursing Home District, their officers, agents and employees, for any statements, acts or omissions in the course of their investigation into my backgrounds, criminal record, (adult or juvenile), family, personal habits, and reputation. I further realize that it may be necessary for Morningside Center Nursing Home and Assisted Living Apartments to thoroughly investigate all aspects of my personal background and qualifications and, by applying for employment with Morningside Center Nursing Home and Assisted Living Apartments, expressly waive all of my legal rights and causes of action to the extent that the Morningside Center Nursing Home and Assisted Living Apartments investigation (for purpose of evaluating my suitability or application for employment) may violate or infringe upon those aforementioned legal rights and causes of action of mine. This release from liability given by me to Morningside Center Nursing Home and Assisted Living Apartments, the Board of Directors of Livingston County Nursing Home District, their officers, employees, agents, and all others as heretofore provided, shall apply to any right of action that might accrue to myself, my heirs, and my personal representatives. Signature * Clear Signature Print Name *Date *NextCRIMINAL RECORD REVIEW 660.317.5 AN APPLICANT FOR A POSITION THAT HAS CONTACT WITH PATIENTS OR RESIDENTS OF MORNINGSIDE CENTER SHALL: SIGN A CONSENT FORM AS REQUIRED BY SECTION 43.540 RSMO, SO MORNINGSIDE CENTER MAY REQUEST A CRIMINAL RECORD REVIEW. DISCLOSE THE APPLICANT’S CRIMINAL HISTORY. CRIMINAL HISTORY INCLUDES ANY CONVICTIONS OR A PLEA OF GUILTY TO A MISDEMEANOR OR FELONY CHARGE AND SHALL INCLUDE ANY SUSPENDED IMPOSITION OF SENTENCE, ANY SUSPENDED EXECUTION OF SENTENCE, OR ANY PERIOD OF PROBATION OR PAROLE; AND DISCLOSE IF THE APPLICANT IS LISTED ON THE EMPLOYEE DISQUALIFICATION LIST AS PROVIDED IN SECTION 660.315. I HAVE READ AND UNDERSTAND THE ABOVE QUALIFICATIONS FOR APPLICANTS AS REQUIRED REGARDING CRIMINAL RECORD REVIEW. Signature * Clear Signature Print Name *Date: *NextEMPLOYMENT-AT-WILL You are applying for an Employment-at-Will position. Nothing in this application is intended to represent a contract for or a guarantee of employment. This application does not constitute a contract. No statements or representations by any representative of the Center shall be construed to confer a guarantee of employment for any period of time unless said representation is in writing and signed by the administrator and is approved by the Board of Directors of Morningside Center. The management and Board of Directors at Morningside Center reserve the right to extend or terminate employment at anytime, for any reason, within the bounds of Federal and State employment regulations. I understand that if I am employed I will not have a contract for, nor a guarantee of employment but will be governed by the Employment-at Will doctrine. I understand that no statements or representations made to me by any representative of Morningside Center shall be construed to infer a guarantee of employment for any period of time unless said representation is in writing and signed by the administrator and has been approved by the Board of Directors of Morningside Center. I further understand that the management and/or the Board reserves the right to extend or terminate my employment at anytime, for any reason, within the bounds of Federal and State employment regulations. Signature * Clear Signature Print Name *Date *An Equal Opportunity Employer – Services provided on a nondiscriminatory basis. NextAPPLICANT’S (FOR EMPLOYMENT) WAIVER OF LIABILITY AND RELEASE FORM READ CAREFULLY BEFORE SIGNING: In order to permit Morningside Center Nursing Home and Assisted Living Apartments to make a thorough investigation of my background, criminal record (adult and juvenile), health, family, personal habits and reputation for employment with said entity, I hereby release from liability and promise to hold harmless from any liability under any and all possible causes of legal action any and all persons who shall furnish any information or opinions regarding my background, criminal record (adult or juvenile), health, family, personal habits or reputation. The undersigned hereby authorizes any person or legal entity who may be contacted by Morningside Center Nursing Home and Assisted Living Apartments, its officers, agents, or employees to release and transmit to such officers, agents or employees, any information, data, or opinions they may have regarding my background, criminal record (adult or juvenile), health, family, personal entities contacted by Morningside Center Nursing Home and Assisted Living Apartments any and all legal privileges I may have to maintain such information as confidential, including but not limited to the following privileges: Attorney-client, physician-patient, psychotherapist-patient, clergyman-penitent, husband-wife, and accountant-client. The undersigned further agrees to hold harmless and release from liability under any and all possible causes of legal action Morningside Center Nursing Home and Assisted Living Apartments, the Livingston County Nursing Home District, their officers, agents and employees, for any statements, acts or omissions in the course of their investigation into my backgrounds, criminal record (adult or juvenile), family, personal habits, and reputation. I further realize that it may be necessary for Morningside Center Nursing Home and Assisted Living Apartments to thoroughly investigate all aspects of my personal background and qualifications and, by applying for employment with Morningside Center Nursing Home and Assisted Living Apartments, expressly waive all of my legal rights and causes of action to the extent that the Morningside Center Nursing Home and Assisted Living Apartments investigation (for purpose of evaluating my suitability or application for employment) may violate or infringe upon those aforementioned legal rights and causes of action of mine. This release from liability given by me to Morningside Center Nursing Home and Assisted Living Apartments, the Board of Directors of Livingston County Nursing Home District, their officers, employees, agents, and all others as heretofore provided, shall apply to any right of action that might accure to myself, my heirs, and my personal representatives. READ CAREFULLY BEFORE SIGNING Signature * Clear Signature Print Name *Date *Submit
