APPLICATION FOR EMPLOYMENT

FOR OFFICE USE ONLY

Name: ________________________________________ Salary __________ Shift ___________

Orientation Date______________ Time________

MHCA Background check done on ________________________ Results: _____ Yes _____ No

Listed on E.D.L.?
Yes ___ No ____ Confirmation #_________________________________
Date __________ Initials ___________

Found on OIG Exclusions List?

Yes ___ No ___
Date __________ Initials ___________

CNA/CMT in good standing? Yes ___ No ___

LPN/RN in good Standing? Yes ___ No ___
Date __________ Initials ___________ Applied for ________________________

Family Care Safety Registration

Registered: Yes ___ No ___ Date __________ Initials ___________
Results: _______________________________________________________________________
_______________________________________________________________________

COVID Vaccine:
Yes ____ No ____
If yes: Name of Vaccine___________________________________
Round #1 Round #2
When: _________________________ When: _________________________
Notes: ___________________________________________________________________________

pg. 1
 APPLICATION FOR EMPLOYMENT

POSITION APPLYING FOR ________________________________ DATE____________________

NAME__________________________________________________________________________
Last First Middle Name

Any Maiden / Alias / Previous Name(s) __________________________________________

___________________________________________

___________________________________________
(If none, please indicate N/A)

ADDRESS _______________________________________________________________________
Street City State Zip

TELEPHONE ( ) _____________________

CELL PHONE ( ) _____________________

(Area code + number)

EMAIL __________________________________________________________________________

SEX: MALE _____ FEMALE _____ RACE ___________________________________

DATE OF BIRTH ___________________________________
Month Date Year
SOCIAL SECURITY # _____________________________

Are you at least 18 years of age? _____ yes _____ no

Shift you can work: ____ Day ____ Evening ____ Nights

Hours desired: ____ Full Time ____ Part Time ____ PRN Pay Expected _________

Have you ever applied for employment with us before? ____ yes ____ no
If yes, Month/Year ____________________________

Have you ever been employed by Garden View Care Center before? ____ yes _____ no
If yes, Month/Year employed _______________________

pg. 2
 APPLICATION FOR EMPLOYMENT

I _________________________ in accordance with the provisions of Missouri law (660.317.5) disclose

that I have a criminal history (convicted of a crime) in Missouri, ____ yes ____ no.

All States And/Or Countries You have Lived in: (Including Missouri or Illinois)

______________________ ______________________ ______________________

______________________ ______________________ ______________________

INITIAL ONE:

________ I have a criminal history in the following states:

______________________ ______________________ ______________________

________ I have no criminal history in any state in United States.

EDUCATION
College __________________________________________________________________________

Did you graduate? ____________ Degree/Diploma ____________________________

Trade or Technical School ___________________________________________________________

Did you graduate? ____________ Degree/Diploma ___________________________

High School ______________________________________________________________________

Did you graduate? ____________ Degree/Diploma _____________

pg. 3
 APPLICATION FOR EMPLOYMENT

Military: Did you serve in the U.S. Armed Forces? _____ Yes _____ No

If yes, in what branch? _____________________________

REFERENCES

1. Name: ___________________________________________
Relationship: ______________________________________
Years Known: _____________________________________
Telephone Number: _________________________________
Comments (FOR OFFICE USE ONLY): __________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________

2. Name: ___________________________________________
Relationship: ______________________________________
Years Known: _____________________________________
Telephone Number: _________________________________
Comments (FOR OFFICE USE ONLY): __________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________

3. Name: ___________________________________________
Relationship: ______________________________________
Years Known: _____________________________________
Telephone Number: _________________________________
Comments (FOR OFFICE USE ONLY): __________________
pg. 4
 APPLICATION FOR EMPLOYMENT

__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________

EMPLOYMENT HISTORY

Company Name: _____________________________________ Telephone _______________

Address: ____________________________________________________________________

Name of Supervisor: __________________________________________________________

May we contact? Yes ____ No ____ (If no) Reason: _______________________________

Employed (month/year) From: ________________ To :__________________

Hourly Pay:________________ Reason for Leaving: ________________________________

********************************************

Company Name: _____________________________________ Telephone _______________

Address: ____________________________________________________________________

Name of Supervisor: __________________________________________________________

May we contact? Yes ____ No ____ (If no) Reason: _______________________________

Employed (month/year) From: ________________ To :__________________

Hourly Pay:________________ Reason for Leaving: ________________________________

**********************************************

Company Name: _____________________________________ Telephone _______________

Address: ____________________________________________________________________

pg. 5
 APPLICATION FOR EMPLOYMENT

Name of Supervisor: __________________________________________________________

May we contact? Yes ____ No ____ (If no) Reason: _______________________________

Employed (month/year) From: ________________ To :__________________

Hourly Pay:________________ Reason for Leaving: _________________________________

The information provided in this application

for employment is true, and complete.

If employed, any misstatement or omission

of fact on this application may result in
dismissal.

I understand that acceptance of an offer of

employment does not create a contractual
obligation upon the employer to continue to
employ me in the future.

Your signature provides consent to Garden View to

verify all references listed on this application.

pg. 6
 APPLICATION FOR EMPLOYMENT

Print Name: ________________________

Signature: _________________________
Date ________________

CRIMINAL RECORD CHECK

PURPOSE: EMPLOYMENT IN A NURSING HOME

AUTHORIZATION: I AUTHORIZE GARDEN VIEW CARE CENTER TO

PROVIDE CENTRAL REPOSITORY WITH INFORMATION NECESSARY TO
COMPLETE REQUIRED RECORD SEARCH.

I AUTHORIZE A PAYROLL DEDUCTION OF $16.50 TO PROCESS REQUIRED

RECORD SEARCH.

I AUTHORIZE A PAYROLL DEDUCTION OF $14.00 TO PROCESS

REGISTRATION FOR THE MFSCR (MISSOURI FAMILY SAFETY CARE
REGISTRY) IF I AM NOT REGISTERED AT TIME OF EMPLOYEMENT WITH
GARDENVIEW CARE CENTER.

pg. 7
 APPLICATION FOR EMPLOYMENT

PRINT NAME: ______________________________________________________________________

Last First Middle

_________________________________________________/____________
Signature Date

REQUEST FOR INFORMATION

COMPANY NAME:
___________________________________________________________________________

FORM COMPLETED BY: _____________________________________ POSITON: ________________________

COMPANY PHONE NUMBER: ________________________________________

I HAVE APPLIED FOR EMPLOYEMENT WITH GARDEN VIEW CARE CENTER AT CHESTERFIELD, AND I DESIRE THAT
THEY BE ADVISED OF MY RECORD WITH PRIOR EMPLOYERS.

I, THEREFORE, REQUEST THAT YOU FURNISH THE FOLLOWING INFORMATION.

NAME USED DURING MY EMPLOYEMENT: _______________________________________________________

Last First Middle
DATES OF EMPLOYEMENT: FROM: ______________________________ TO: __________________________

SOCIAL SECURITY #: _______________________________________

ELIGIBLE FOR REHIRE? _______ YES _______ NO

IF NO WHY: ________________________________________________________________________________
__________________________________________________________________________________________

pg. 8
 APPLICATION FOR EMPLOYMENT

____________________________________________________ __________________
SIGNATURE OF APPLICANT DATE

PLEASE COMPLETE AND RETURN TO:

GARDEN VIEW CARE CENTER AT CHESTERFIELD

1025 Chesterfield Pointe Parkway
Chesterfield, MO 63017
Phone: (636) 537 – 3333
Fax: (636) 530 – 9755

pg. 9