Printable Job Application

Application for Employment

Please fill out form completely for employment consideration. Print and fax or mail when
completed.

Prospective employees will receive consideration without discrimination because of race, creed,
color, sex, age, national origin or handicap. We are an equal opportunity employer.
Personal Information
Last Name First Middle Date
1-16-18
Hanson Madison Jo
Street Address Home Phone
( N/A )
208 9th St. N Ph. 641-381-xxxx -
City, State, Zip

Northwood, IA, 50459

Business Phone Email Address:
( ) -
N/A
18mhanson@n
What was your previous address?
kstudents.com
How long at present
previous
address?

N/A _________ Years

________ Months
Are you over 18 years of age? Yes No How long at present
If not, employment is subject to verification of minimum legal age. address?
5
_________ Years
________
7 Months
Have you ever applied for employment with us? Social Security No.
Yes No
If Yes: Month and Year__________ Location______________________________ - -
************
How did you learn of our organization?

Through High School Counselor

Are you legally eligible for employment in the United States? When will you be able to work?

Yes

Are you employed now? If so, may we inquire of your present employer?
Yes Lutheran Retirement home

Have you been convicted of a crime in the past ten years, excluding misdemeanors and summary
offenses, which has not been annulled, expunged or sealed by a court? Yes No If
Yes, describe in full.

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Printable Job Application

Are there any reasons for which you might not be able to perform the job duties (with a
reasonable accommodation)?
Yes No If Yes, please explain.

Drivers License# State Any Violations?

xxxxxxxxxx Iowa Yes No

Education

No. of
Course of Did you Degree or
School Name and location of school years
study graduate? diploma
completed
College Yes
NIACC Gen Eds. 1 No
High Yes
Northwood-Kensett 3 1/2 No
Trade Yes
School N/A No
Other Yes
N/A No

Military
Complete this section if you served in the U.S. Armed Forces Branch of Service

N/A
Describe your duties and any special training Period of Active Duty (Month & Year)

From To
Rank at Discharge
Date of Final Discharge

Employment History Please give accurate, complete full-time and part-time employment
record. Start with present or most recent employer.

Company Name Telephone

Lutheran Retirement Home ( )641-324-1712 -
Address Employed (Start Month and Year)
701 9th St. N, Northwood,IA 50459
FromJuly 2017 To present
1.
Name of Supervisor Hourly Rate
Kris Jacobs
Start 13.50 Last 15.50
Start Job Title and Describe Your Work Reason for Leaving
CNA/ Nursing
Assistant

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Printable Job Application

Company Name Telephone

Lutheran Retirement Home ( )
641-324-1712 -
Address Employed (Start Month and Year)
701 9th St. N, Northwood,IA
50459 FromApril 2015 To July 2017
2.
Name of Supervisor Hourly Rate
Nancy Frank
Start 9.90 Last 11.10
Start Job Title and Describe Your Work Reason for Leaving
New Job Opportunity
Dietary Aide
Company Name Telephone
Northwood-kensett Summer Food Program ( )
641-324-1127-
Address Employed (Start Month and Year)
May
1200 1st Ave. N, Northwood, IA 50459
From 2015 ToJuly 2015
3.
Name of Supervisor Hourly Rate

Peter Julseth Start 7.25 Last 7.25

Start Job Title and Describe Your Work Reason for Leaving
Kitchen worker Job Ended
Company Name Telephone
N/A ( ) -
Address Employed (Start Month and Year)

From To
4.
Name of Supervisor Hourly Rate

Start Last
Start Job Title and Describe Your Work Reason for Leaving

Do not contact
We may contact the employers listed above
unless you indicate those you do not want us to Employer Number(s)_____________________
contact. Reason____________________________

References: Give below the names of three persons not related to you, whom you have known at
least one year.
Years
Name Address Business
Acquainted
1.
Julia Olson 390th 3rd St. Joice, IA, 50459 Pharmacy @ Shopko 2
2.
Jessie Wiesel 76th 15th St. Floyd, IA, 50459 Nurses Aide @ LRH 2
3. Lidseny
Janzig 390th 2nd St. Albert Lea, MN, 56007 Mayo Clinic 2

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Printable Job Application

The information provided in this Application for Employment is true, correct and complete. If
employed, any misstatements or omissions of fact on this application may result in my dismissal.
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.
If you decide to engage an investigative consumer reporting agency to report on my credit and
personal history, I authorize you to do so.
If a report is obtained you must provide, at my request, the name and address of the agency so I
may obtain from them the nature and substance of the information contained in the report.

1-16-18
___________________ _________________________________
Date Signature

Please complete and mail or fax a copy of this form to:

Environmental Recycling
Attn: Human Resources
PO Box 167, Bowling Green, Ohio 43402
Phone (419) 354-6110
Fax (419) 354-5110

http://www.envrecycle.com/

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