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Employment Application
Name: Wahl Last Telephone: 641-390-1009 Address:
108 4th St. N Abigail

COMPANY OR EMPLOYER NAME:

Lutheran Retirement Home

Position applying for:

Dietary Home

EMPLOYEE INFORMATION
Sue

First Email: 14awahl@nkstudent.com

Middle Alternate telephone: 641-324-3060

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 No Work overtime? Yes No Provide a valid Alaska Driver's License? Iowa If so, fill out the following: Issuing state: Type: Endorsement(s):
Hazardous Material Tankers School Bus Any Split Day Night Other: Passengers Tank with Hazardous Materials Double/Triple trailers Swing Rotating

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

Work the following shifts: (check all that apply)

Graveyard

I will be able to report to work 14 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:

Position title/duties, skills:

Nancy Frank
Pay: $ 8.65 Per: hour Employer name and address:

Dietary aide, Make special drinks and desserts. Set tables, and do dishes
Supervisor: Nancy Frank Telephone: 641-324-1712 Position title/duties, skills:

May 2013

Start date:

End date:

Present

Reason for leaving:

Still employed
Start date: End date:

Dedra Harris City of Northwood

Basket house and Concession Stand Handled money and served food
Supervisor: Dedra Harris Position title/duties, skills: Telephone:

May 2010

August 2010

Reason for leaving:

Pay: $ 4.75 Per: hour Employer name and address:

Summer job only

Start date: End date:

641-324-1680 May 2010 July 2013

Reason for leaving:

Rhonda Taylor 728 Central Ave

Pay: $ 4.25 Per: hour Employer name and address:

Washed dishes, served food, handled money

Carrer change
Supervisor: Rhonda Taylor Telephone: Position title/duties, skills:

641-324-1052

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

Graduate May 18, 2014

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

** No SKILLS & QUALIFICATIONS

N/A

Other qualifications such as special skills, abilities or honors that should be considered: Types of computers, software, and other equipment you are qualified to operate or repair: Professional licenses, certifications or registrations:

N/A

N/A

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
Typing speed:

70

per minute

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

Jodie Bachtle
Name Name

Address Address

110 2nd St. N

Telephone Telephone

641-324-1915

Occupation Occupation

Photography

17
Years known

Dayna Hickman

1712 Central Ave.

641-324-1912 CONTACT

Mercy Medical Center

17

Years known

In case of accident or illness, please contact: Name: Address: 1012 12th St. S

June Nerlien

Daytime phone: Relationship:

641-324-1222 Grandmother

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.

Abigail Wahl
Signature of Applicant

2/7/14
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