Application – LaSalle Nursing Home

Employment Applicaton

Application for Employment

LaSalle Nursing Home 139 9th Street Jena LA 71342
AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER

THIS FACILITY IS AN EQUAL EMPLOYMENT OPPORTUNITY EMPLOYER. WE RECRUIT, HIRE, TRAIN, AND EMPLOY WITHOUT DISCRIMINATION DUE TO RACE, COLOR, RELIGION, NATIONAL ORIGIN, ANCESTRY, DISABILITY, SEX, MARITAL STATUS, OBLIGATION TO SERVE IN THE ARMED FORCES OF THE UNITED STATS, OR ANY OTHER CHARACTERISTIC PROTECTED BY APPLICABLE FEDERAL OR STATE LAW.

IMPORTANT NOTICE

IT IS A CRIME IN LOUISIANA TO KNOINGLY AND INTENTIONALLY PROVIDE FALSE INFORMATION ON THIS EMPLOYMENT APPLICATION OR TO PROVIDE FALSE ORAL STATEMTNS DURING EMPLOYMENT INTERVIEWS IN ORDER TO OBTAIN EMPLOYMENT AS A CARETAKER AT THIS FACILITY, IF THE FALSE INFORMATION IS RELEVANT TO THE CARETAKING OBLIGATION. LA. R.S. 14:126:3.

Section 1

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Date:

Name *

First

Last

Position Appling For:

Are You Appling For: *

Full Time
Part Time
Temporary

If seeking part-time, please enter the number of days per week.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Best Contact Phone Number

Perferred Email Address

Are you either a U.S. citizen or an alien who has the legal right to work in the job(s) for which you are appling?

Are you 18 or older?

Have you ever been employed by this facility?

If Yes, please list the position and department employed

Have you ever applied at this facility before?

If Yes, When

Do you have relatives or friends employed at this facility?

If Yes, please list names

Have you ever been convicted of any crime other than a minor traffic violation?

A criminal conviciton will not necessarily be a bar to employment. To help us evaluate you application, plese decribe the naure of the crime any your subsequent rehabilitation.

Have you ever been disciplined for resident or patient abuse?

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

If Yes, explain fully (A yes answer is not an automatic bar from employment.)

How soon are you available to begin employment?

How were you referred?

Newspaper AD
Employee Referral
Health Fair
Friend/Relative
Social Media
ReHire

Shift Preference

Day
Evening
Night

If required, will you work?

Saturdays
Sundays
Holidays
Rotating Shifts

Section 2

Section 2 of this application pertains to past employment history, educational background, licenses/certifications, references. and special skills. You may enter this information into the online form or you may use the "Upload Resume" button to send you resume. Uploaded resumes are preferred.

Please mark the your perferred method of submitting the requested information:

I perfer to upload my resume
I perfer to manually enter the information

Resume Upload

Your resume will be upload when you click the submit button at the end of the application

Beginning with your current or last employer list the last four postions of employment held in date order. Please include Name and address of employer, position held, dates of employment, supervision name and contact, and reason for leaving.

Reference #2

Reference #3

Reference #4

Educational Background

Please enter the names and attendance dates of each school you attended beginning with high school. Also include the last year completed and any degrees obtained

Section 3

Professional Licenses and Certifications

License Type

License Number

State Issued

Dates License is Valid

Military Service

If you obtained any experience or skills while in military service that relates to the job for which you are applying, please describe the nature of your duties that led to the experience.

References

Name

Address

Contact

Relationship

Name

Address

Contact

Relationship

Additional Information

Please include any additional information that you think wild be applicable: e.g., internships, membership in professional organizations, additional relevant employment, and explanation of any gaps in employment. Do not provide any information which would denote race, sex , age, marital status, disability, national origin, ancestry, religious, or political affiliations, or any other characteristic or status protected by federal or state law.

Section 4 ATTESTATION

IMPORTANT STATEMENTS - READ CAREFULLY BEFORE SUBMITTING - I AUTHORIZE THE INVESTIGATION OF ALL STATEMENTS CONTAINED ON THE APPLICATION AND THE REFERENCES LISTED TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, AND RELEASE ALL PERSONS FROM ALL LIABILITY AND DAMAGES THAT MAY RESULT FROM FURNISHING THAT INFORMATION TO YOU. I UNDERSTAND THAT LASALLE NURSING HOME MAY CONDUCT A BACKGROUND CHECK, WHICH MAY INCLUDE A REVIEW OF CRIMINAL HISTORY RECORDS, DRIVING RECORDS, PRIOR EMPLOYMENT HISTORY, EDUCATIONAL BACKGROUND AND/OR OTHER RECORDS. I UNDERSTAND THAT THE BACK GROUND CHECK MAY ALSO INCLUDE A REVIEW OF MY BACKGROUND BY MEANS OTHER THAN A REVIEW OF PUBLIC RECORDS. I CONSENT TO ALLOWING LASALLE NURSING HOME TO CONDUCT THIS BACKGROUND CHECK. IN CONSIDERATION OF MY EMPLOYMENT, I AGREE TO COMPLY WITH THE RULES, REGULATIONS, AND POLICIES OF LASALLE NURSING HOME, AND ACKNOWLEDGE THAT THESE RULES, REGULATIONS AND POLICIES MAY BE CHANGED A ANY TIME WITH OR WITHOUT NOTICE FOR ANY REASON NOT VIOLATIVE OF THE LAW. I ALSO AGREE AND UNDERSTAND THAT MY EMPLOYMENT AND COMPENSATION ARE AT WILL, AND CAN BE TERMINATED , WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE, AT ANY TIME, AT THE OPTION OF EITHER LASALLE NURSING HOME OR MYSELF. I ALSO UNDERSTAND AND AGREE THAT THE TERMS AND CONDITIONS OF MY EMPLOYMENT MAY BE CHANGED, WITH OR WITHOUT CAUSE, AND WITH OR WITHOUT NOTICE AT ANY TIME BY LASALLE NURSING HOME, I ALSO UNDERSTAND THAT NO REPRESENTATIVE OF LASALLE NURSING HOME, OTHER THAN ITS ADMINISTRATOR, HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FOREGOING. I CERTIFY THAT HAVE READ AND UNDERSTAND THE FOREGOING PARAGRAPHS. I FURTHER CERTIFY THAT ALL THE INFORMATION SUBMITTED BY ME ON THE APPLICATION IS TRUE AND COMPLETE TO THE BEST OF KNOWLEDGE, AND I UNDERSTAND THAT ANY FALSE INFORMATION, OMISSIONS, OR MISREPRESENTATIONS OF FACTS CALLED FOR ON THIS APPLICATION MAY BE CAUSE FOR THE DENIAL OF MY APPLICATION OR, IT I AM EMPLOYED, DISCHARGE AT ANY TIME. I ALSO UNDERSTAND THAT FALSIFICATION OF INFORMATION ON THE APPLICATION OR DURING THE HIRING PROCESS CAN ALSO BE A CRIME, AND MAY ALSO BE USED AS A BASIS FOR DISQUALIFICATION FROM WORKERS COMPENSATION BENEFITS. AS A CONDITION OF EMPLOYMENT I HEREBY CONSENT TO TESTING FOR DRUG AND /OR ALCOHOL USE, AS DETERMINED TO BE APPROPRIATE BY MANAGEMENT, EITHER BEFORE BEING HIRED, AND AFTER BEING MADE A CONDITIONAL OFFER OF EMPLOYMENT, AND/OR AT ANY TIE DURING MY EMPLOYMENT WITH LASALLE NURSING HOME.

PLEASE TYPE NAME/DATE AND CLICK SUBMIT *

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