List current or most recent job first, and continue with preceding jobs.
Professional Licenses/or Certifications
College, University, or Technical School
*Note: A criminal record does not constitute an automatic bar to employment, it will only be considered as it relates to the job for which you are applying. You are not required nor will you be asked to report whether you have a sealed conviction or arrest.
Please indicate days and hours you are available for work. (Be specific)
If your availability changes, it is your responsibility to fill in an "Availability Card" indicating the changes. Such changes will be effective, then, for any future employment.
I understand that emergency conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling change as directed by my department head or administration of this institution.
Employment Understanding (Please read and sign)
This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, Vietnam-era veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination.
I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take the physical examination, and such future physical examinations as may be required by this institution at such times and places as the institutioin shall designate. I understand that an offer of employment may be contingent on passing the physical examination which relates to the essential duties I would be required to perform.
I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or mission of fact appearing on this application form.
If employed, I will be required to complete an Employment Verfication Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.
Employment Application Addendum
PLEASE READ CAREFULLY BEFORE SIGNING:
I certify that the above answers given are true and complete to the best of my knowledge. I understand that the Facility may investigate all statements made in the Application and that any false or misleading information provided can result in a decision not to hire; immediate discharge if hired, and civil or criminal penalties as appropriate. I further understand that this Addendum is considered part of the original Applicatiion for Employment and shall be incorporated therein,
IOWA HEALTH CARE FACILITY (135C) RECORD CHECK
Iowa Division of Criminal Investigation
Bureau of Identification, 1st Floor
215 E 7th Street
Des Moines, IA 50319
(515) 281-5138 (Voice-days)
(515) 281-4776 (Voice-nights)
(515) 242-6876 (Fax)
Crestview Nursing & Rehab
2401 Des Moines St.
Webster City, IA 50595
I am requesting an IOWA CRIMINAL HISTORY check on:
I hereby give permission for the above requesting official to conduct an Iowa criminal history record check with the Division of Criminal Investigation. Any information maintained by the DCI my be released as allowed by law.