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Employment Application
Name: Jaspers Last Telephone: 1-641-324-0000 Address:


Lutheran Retirement Home

Position applying for:

Nurses Aide


First Email:

Middle Alternate telephone: 1-641-390-0000

1307 Central Avenue Northwood, IA 20459

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? If so, fill out the following: Issuing state: Iowa 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)


I will be able to report to work 14 days after being notified I am hired.

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:

Northwood Swimming Pool 6207 Central Avenue IANorthwood, Northwood, IAIa 50459 Pay: $ 5.50

Position title/duties, skills:

Basket House Use Telephone Use Cash Register Maintenance

Start date:

End date:

Reason for leaving:

Per: Hour Employer name and address:

Northwood Swimming Pool 6207 Central Avenue IANorthwood, Northwood, IAIa 50459 Pay: $ 7.50

Supervisor: Dedra Harris Position title/duties, skills:

Life Guard Certied in First Aid & CPR Maintenace Work

Telephone: 1-641-324-1001

Moved to Life Guard Position

Start date:

End date:

Reason for leaving:

Per: Hour Employer name and address:

Supervisor: Dedra Harris Position title/duties, skills:

Telephone: 1-641-324-1001

Seasonal Job (Summer)

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

Summarize other employment related to this job:

Institution name High school College/university Business/technical Additional

Years completed

Field of study

Graduate or degree
Graduate May 18, 2014

Are you a veteran? Duty/specialized training: Yes No


Other qualifications such as special skills, abilities or honors that should be considered:
Always punctual, Motivational Attitude, Communication skills, and Self-Condence

Types of computers, software, and other equipment you are qualified to operate or repair:
Operate Apple and Microsoft computers

Professional licenses, certifications or registrations:

Certied in CPR and First Aid

Additional skills, including supervision skills, other languages or information regarding the career/occupation you wish to bring to the employers attention:
two years of high school spanish

Typing speed: 70

per minute

List two personal references who are not relatives or former supervisors.
Mary Christianson Name Mark Willand Name 120 5th St N Address 712 3rd St S Address 641-390-1271 Telephone 641-390-1203 Telephone
Banker Occupation

16 Years known

Youth Director at First Lutheran Church 7 Occupation Years known

In case of accident or illness, please contact: Name: Katy Jaspers Address: 1307 Central Avenue, Northwood, IA 50459 Daytime phone: 1-641-324-1830 Relationship: Grandmother


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.

Katelyn Jaspers


Signature of Applicant


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