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Employment Application


St. Johns Lutheran Home

Position applying for:

Certied Nursing Assistant

Hannah Marae

Last Telephone: 507-402-7296 Address:

First Email:

Middle Alternate telephone: 507-369-5198

703 Cedar Ave, Albert Lea, MN 56007

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: Endorsement(s):
Hazardous Material Tankers School Bus Any Split Day Night Other:

No No


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)


I will be able to report to work 7 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:

Hyvee 2708 Bridge Avenue Albert Lea, MN 56007 Pay: $ 7.35

Position title/duties, skills:

Barista Provide customer service, operate cash register, assemble drinks, and provide a clean work space.

Start date:
April 2013

End date:

Reason for leaving:

I want to pursue a career in health care.

Start date:
Aug. 2012

Per: hour Employer name and address:

McDonalds 2808 Bridge Avenue Albert Lea, MN 56007 Pay: $ 7.50 Per: hour

Supervisor: Ali Weisert Position title/duties, skills:

Telephone: 507-402-9234 End date:

April 2013

Cashier Provide customer service, operate cash register, assemble orders, stock supplies, and provide a clean work space.

Reason for leaving:

Looking for new opportunities.

Start date: End date:

Employer name and address:

Supervisor: Tony Position title/duties, skills:

Telephone: 507-377-2834

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
4 N/A

Field of study

Graduate or degree
High school diploma

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


Other qualifications such as special skills, abilities or honors that should be considered:
I work well with others, and I am a very neat and organized person.

Types of computers, software, and other equipment you are qualified to operate or repair:
Apple and Dell computers; Microsoft and Pages Document

Professional licenses, certifications or registrations:

Certied Nursing Assistant License

Additional skills, including supervision skills, other languages or information regarding the career/occupation you wish to bring to the employers attention:

Typing speed: N/A

per minute

List two personal references who are not relatives or former supervisors.
Logan Bidne Name Lisa Nelson Name Lake Mills, IA Address Albert Lea, MN Address 507-402-4784 Telephone 507-383-8923 Telephone Construction Worker Occupation Social Worker Occupation 1 Years known 5 Years known

In case of accident or illness, please contact: Name: Kelly Aldrich Address: Emmons, MN Daytime phone: 507-318-3190 Relationship: Mother


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. Hannah Buchanan February 6, 2104

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