crestview nursing and rehabilitation

Employment

Current Openings

CNA starting at $19/hr

Click to view job description. Please complete the form below to apply.

RN $30-$35/hr

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Receptionist $12-$15/hr

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LPN $30-$35/hr

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Housekeeper $13.50-$14/hr

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To begin the process, please complete the form below and click “Submit”. We will be in touch to discuss our opportunities!

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Today's Date

Name - Last, First, M.I.

Social Security #

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Position applying for

Are you at least 16 years old?

If under 18, what is your birthdate?

Are you applying for part-time work or full-time work?

Part-time
Full-time

Date you would be available to begin work

Employment History
List current or most recent job first, and continue with preceding jobs.

May we contact your previous supervisor(s) for a reference?

Employer #1

Name of Employer

Phone

Job Duties

Address

Hired (Month, Year) End (Month, Year)

Reason for leaving and date

Supervisor

Salary at end

Employer #2

Name of Employer

Phone

Job Duties

Address

Hired (Month, Year) End (Month, Year)

Reason for leaving and date

Supervisor

Salary at end

Employer #3

Name of Employer

Phone

Job Duties

Address

Hired (Month, Year) End (Month, Year)

Reason for leaving and date

Supervisor

Salary at end

Professional Licenses/or Certifications

Type

Organization or State Issued

Date Issued

Number

Personal References

Name

Telephone

Relationship

Years Known

Educational History

High School

High School Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

College, University, or Technical School

School Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Are you involved in any activities which would conflict with your assigned work schedule?

List any training, skills, and qualifications which you feel are relevant to the type of employment you are seeking here

Have you ever been convicted of a felony or misdemeanor crime that has not been removed from your record?

If Yes, state date, place and nature of conviction*

*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.

Have you ever been discharged or asked to resign from any position?

If Yes, please explain

Please indicate days and hours you are available for work. (Be specific)

Sunday From

Monday From

Tuesday From

Wednesday From

Thursday From

Friday From

Saturday From

Sunday To

Monday To

Tuesday To

Wednesday To

Thursday To

Friday To

Saturday To

Availability Record

Primary position desired

Will you accept another position?

If so, what?

Are you available to work

Weekends
Holidays
Rotating Shifts

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.

Signature

Date

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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.

Signature

Date

Employment Application Addendum

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Date of Birth

Social Security Number

Professional License Number

Position applying for

Provide all other names or aliases you have ever previously been know by, including but not limited to nicknames, maiden names, and other married names.

Do you have knowledge, or have you ever been notified of being placed on the OIG Excluded Provider List or Excluded Parties List Service (EPLS.gov) maintained by the General Services Administration (GSA)? If yes, please specify the date and reason. (Even if you were at one time on such list and have since been removed, please indicate)

Have you ever had a professional license subject to suspension or revocation? If yes, please specify the date and the reason.

Have you ever involuntarily relinquished your professional license? If yes, please specify the date and reason.

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,

Signature

Date

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IOWA HEALTH CARE FACILITY (135C) RECORD CHECK
Form C

ACCOUNT NUMBER: 1629-C

TO:
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)

FROM:
Crestview Nursing & Rehab
2401 Des Moines St.
Webster City, IA 50595
Phone# 515-832-2727
Fax# 515-832-2761

I am requesting an IOWA CRIMINAL HISTORY check on:

Last Name

Maiden Name

Date of Birth

Signature of Requester

First Name

Sex

Middle Name

Social Security Number

WAIVER

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.

Signature (Applicant)

Date

Form No. 595-1489 (4/07)

Contact Us

For More Information

Crestview Nursing and Rehabilitation
2401 Des Moines St.
Webster City, IA 50595

P: 515-832-2727
F: 515-832-2761
mwhitmore@crestviewnrc.com

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