Application Paper - Pinecone Health LLC

GENERAL PRESONAL INFO

Name *

First

Last

Phone Number *

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth *

Social Security Number *

Driver’s License Number *

State where Driving License was Issued *

Position Desired *

Select you desired position

Date Available *

Total Hours Available Per Week

Years of work experience *

Shift Desired *

AM Shift
PM Shift
Night Shift
Weekends

Are you legally able to accept employment in the United States of America? *

Yes
No

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

Yes
No

Answering "yes" will not automatically disqualify you.

If the above answer is yes, then please explain

EDUCATION

Enter the type of schools you have attended. Enter all which is apply to you.

High School Name and Location (City and State) *

Diploma

Yes
No

GED

Yes
No

Vocational Training, Name and Location (City and State)

What is your Field of Study

Do you have a Vocational Certificate

Yes
No

College or University. Name and Location (City and State)

What is your Major

Did you graduated with a Degree

Yes
No

CERTIFICATE AND LICENSE INFO

Which Position are you applying for? *

RN/LPN License Number *

License Expiration Date *

License Verification Date *

Are you registered with Minnesota State ? *

Yes
No

TMA Date of Certification *

Certificate Expiration Date *

Certificate Verification Date *

CNA Date of Certification *

Certificate Expiration Date *

Certificate Verification Date *

CERTIFACATE RESTRICTIONS

Does your LicenseCertificate: Have any current restrictions? Ever been investigated or incumbered? *

Yes
No

If yes, please explain.

STATEMENT OF NON-DISCRIMINATION

Minnesota Professional Nursing Services is an Equal Opportunity employer. It does not discriminate in employment on the basis of race, color, creed, religion, national origin, sex, disability, marital status, sexual orientation, or status with regard to public assistance

Employment History: List previous employment

Start with most recent/present first. If you have not work before leave it blank.

Employer 1

Name of Employer

Busines or company Name

Date Started //

Date Ended//

Address

Address Line 1

Address Line 2

City

State

Zip Code

Business Phone Number

Job Title

Supervisor Name

Work Performed

Reason For Leaving

Employer 2

Name of Employer

Busines or company Name

Date Started//

Date Ended//

Address

Address Line 1

Address Line 2

City

State

Zip Code

Business Phone Number

Job Title

Supervisor Name

Work Performed

Reason For Leaving

Have you ever been employed under a different name? *

Yes
No

If Yes enter Name

Have you ever been discharged or asked to resign from a position? *

Select yes or no

If yes explain

PERSONAL REFERENCES

DO NOT LIST RELATIVES OR FORMER EMPLOYERS

1. Reference

Name *

Phone *

Time or Duration Known *

2. Reference

Name

Phone

Time or Duration Known

APPLICANT AGREEMENT:

I understand that this employment application and any other documents presented to me in the course of applying for a position with PINCONE are not contracts of employment. I also understand that if I am hired, I will be an at-will employee, which means I may voluntarily leave employment upon proper notice and may be terminated by PINCONE at any time for any reason. I understand that any oral or written statements to the contrary are expressly disavowed and should be relied upon. I understand that any offer of employment by PINCONE is contingent upon (1) providing sufficient documentation necessary to establish my identity and eligibility to work in the United States, (2) successful completion of any preemployment physical examination and/or drug screening test that may be required by PINCONE, (3) successful completion of a Mantoux test or chest x-ray (if previous Mantoux test has been positive) in compliance with the Minnesota Department of Health's regulations, and (4) successful completion of any background checks which are performed by PINCONE. I authorize PINCONE to investigate all statements on this application, including work and education references. I authorize my previous employer, work and/or education related references, and educational institutions I have attended to provide PINCONE with all documents and information which it requests in conjunction with my application for employment. I specifically release and waive any and all claims, including, but not necessarily limited to, claims for defamation, libel, and slander, that I may have against any such individual or institution as a result of their compliance with PINCONE's request for information. I understand that any false statements or omissions in this application form made in the course of applying for employment a PINECONE may disqualify me for employment or lead to my subsequent dismissal from employment. My signature reflects that I have read, understood, and agreed to these conditions without reservation.

SIGNATURE

Print your full name and Date

Name *

Date *

Authorization to Release Information

You need to provide authorization for Minnesota Department of Human Services to conduct a background study.

I understand that as part of the application process for employment with Pinecone Health LLC, if I am offered employment, a background investigation of my criminal history will be conducted. Additionally, records of substantiated maltreatment of vulnerable adults and children may also be reviewed. I authorize any of the below lasted agencies to release information, and I release them from any liability as a result of such inquires or disclosures. I understand that any offer of employment is conditional upon the results of the investigative report, and that failure to provide information necessary to ensure an accurate and complete background study will result in my disqualification from employment with MINNPRO. I agree that if any misrepresentation has been made by me herein, or the results of such investigation are not satisfactory, any offer of employment made may be withdrawn, or my employment may be terminated immediately. I consent to allow any of the below listed investigative agencies to perform background investigations of my history and to provide Pinecone Health LLC with the results. Possible agencies performing check: Verified Credentials, Minnesota Bureau of Criminal Apprehension, Minnesota Department of Human Services, Federal Bureau of Investigation.

Name

First *

Middle

Last *

Maiden

Other names used/known by

E.nter any other name you have used

Social Security Number *

Driver’s License Number *

Current street address/city/state/zip code

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Duration Lived in the Address

From *//

To *//

Have lived in Minnesota since 2018? *

Select Yes or No

Have you had a Background Check in Minnesota with the las 6 Month? *

Select Yes or No

I would like a free copy of my report sent to me at my current address: *

Select Yes or No

Signature *

Print your Full Name

Date *

Enter Todays Date