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Employment Application
Name: Bass Last Telephone: 1(641)-381-0368 Address:
Blake

COMPANY OR EMPLOYER NAME:

Lutheran Retirement Home

Position applying for:

CNA

EMPLOYEE INFORMATION
Lee

First Email: 14bbass@nkstudents.com

Middle Alternate telephone:

105 9th Street North Northwood, Iowa 50459

Are you able to perform the essential functions of the position with or without accommodations?
Yes 14 18 Yes No 15 19 No Yes No 16 21 (Check one)

If necessary for the job are you older than:

If necessary for the job, I am able to: Yes Work overtime? Yes Provide a valid Alaska Driver's License? If so, fill out the following: Issuing state: Type: N/a Endorsement(s):
Hazardous Material Tankers School Bus Any Split Day Night Other:

No No

N/A
Passengers

I am legally eligible for employment in the U.S.? I am seeking a permanent position:

Tank with Hazardous Materials Double/Triple trailers Swing Rotating

Work the following shifts: (check all that apply)

Graveyard

I will be able to report to work open days after being notified I am hired.

EMPLOYMENT HISTORY
List most recent employment first. Include summer or temporary jobs. Be sure all your experience or employers related to this job are listed here, in the summary following this section or on an extra sheet of paper if necessary. No more than 10 years history recommended.

Employer name and address: Krull Law

Position title/duties, skills: Cleaning, organizing

Start date: July 2009

End date: July 2014

Reason for leaving:

7.50 Pay: $ Per: hour Employer name and address:

College
Supervisor: Doug Krull Position title/duties, skills: Telephone: 1(641)-324-1982 Start date: End date:

Reason for leaving: Pay: $ Per: Employer name and address:

Supervisor: Position title/duties, skills:

Telephone: Start date: End date:

Reason for leaving: Pay: $ Per: Employer name and address:

Supervisor: Position title/duties, skills:

Telephone: Start date: End date:

Reason for leaving: Pay: Per: $ Supervisor: Telephone:

Employment Application Page 1 of 2

Rev. 8/2010

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Summarize other employment related to this job:

EDUCATION
Institution name High school College/university Business/technical Additional Years completed Field of study Graduate or degree

Northwood-Kensett H.S.

General

Graduate (2014)

MILITARY
Are you a veteran? Duty/specialized training: Yes

X No

SKILLS & QUALIFICATIONS

Other qualifications such as special skills, abilities or honors that should be considered: Good with people, Good communication skills, Types of computers, software, and other equipment you are qualified to operate or repair: Any Professional licenses, certifications or registrations: N/A Additional skills, including supervision skills, other languages or information regarding the career/occupation you wish to bring to the employers attention: N/A 100 Typing speed: per minute

REFERENCES
List two personal references who are not relatives or former supervisors.

Brandon Kalvig
Name

1306 2nd Ave. North Norhtwood, IA 50459 1(641)-390-1341

Address Telephone

Psychologist
Occupation

9
Years known

Deb Faugstad
Name

796 11th Street, Northwood, IA

Address

1(641)-374-9204
Telephone

Teacher
Occupation

5
Years known

CONTACT
In case of accident or illness, please contact: Name: Cindy Bass Address: 105 9th Street north, Northwood, Iowa 50459 Daytime phone: 1(641)-390-1338 Relationship: Mother

INFORMATION TO THE APPLICANT

As part of our procedure for processing your employment application, your personal and employment references may be checked. If you have misrepresented or omitted any facts on this application, and are subsequently hired, you may be discharged from your job. You may make a written request for information derived from the checking of your references. If necessary for employment, you may be required to: supply your birth certificate or other proof of authorization to work in the United States, have a physical examination and/or a drug test, or to sign a conflict of interest agreement and abide by its terms. I understand and agree to the information shown above.

Signature of Applicant

February 3, 2014 Date

Equal Employment Opportunity: While many employers are required by federal law to have an Affirmative Action Program, all employers are required to provide equal employment opportunity and may ask your national origin, race and sex for planning and reporting purposes only. This information is optional and failure to provide it will have no affect on your application for employment. Developed at employer request by the Alaska Department of Labor & Workforce Development, Employment Security Division. Rev. 8/2010 Employment Application Page 2 of 2