1405 7th Street South, Moorhead, MN 56560-3497 (218) 233-7508 Fax: (218) 291-2276 www.eventide.org AA/EEO Statement: Eventide is an Equal Opportunity/Affirmative Action Employer. Applicants will receive consideration for employment regardless of race, color, creed, religion, national origin, sex, sexual orientation, disability, age, marital status, or status with regard to public assistance.
Information on Applying: To be considered an applicant, you must submit a fully completed Eventide Application. You may include a resume in addition to the application. For a more complete description of the position and physical requirements, please request the Job Description for the specific position. You may also access our open positions through our 24-hour Job Line at 218-291-2318 on our web site at www.eventide.org or by calling our office directly at 218-291-2224. This application shall be considered active for a period of time not to exceed 2 months. If you are interested in more than 1 position, please list them all on one application.
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| Please check the building (or buildings) in which you would like to work: Nursing Home Linden Tree Circle Catered Living The Fairmont Sheyenne Crossings (West Fargo) |
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| Position(s): *Please be specific on the title of the position or positions* |
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| FT (64 or more hrs/ 2 weeks) PT (63 or less hrs/2 weeks) PRN (As Needed) | ||||||||||||||
Please list the times in each day of the week that you are available to work (ex: 8am – 5pm etc.) Assure that the times match the position for which you are applying.
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| Social Sec. Number - - Are you legally eligible to work in the United States? Yes No | ||||||||||||||
| Were you previously employed by Eventide? Yes No | ||||||||||||||
| If you have ever been employed or attended school under another name, list other name(s) used: | ||||||||||||||
| Are you at least 16 years of age?* Yes No
If not, do you have proof of your age? Yes No * Used only to ensure compliance with state and federal child labor laws. |
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| How did you learn about this opening? | ||||||||||||||
| Is this application for a school-related paid Co-Operative Education experience? Yes No * If yes, please understand that Eventide does not accept paid Co-Operative Education students. | ||||||||||||||
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Have you ever been found guilty by a court of law of abusing, neglecting or mistreating a resident or of misappropriation of their property? Yes No * If yes, under federal regulations, this will disqualify you from consideration for employment at Eventide. |
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Have you ever been convicted of any type of crime? Yes No If yes, give date, offense and type (misdemeanor, gross misdemeanor or felony): * Conviction will not necessarily bar you from employment with Eventide, however, non-disclosure, may bar you from employment with Eventide. Upon hire, a background study will be required by MN Law |
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| Employment & Work References: List your last three (3) employers, assignments or volunteer activities, starting with the Most Recent, including military experience. Explain any gaps in employment in comments section below. |
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| No. 1 | ||||||||||
| Company: Dates: To Your Title: | ||||||||||
Address :
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| Immediate Supervisor's Name & Title: | ||||||||||
| Description of Duties |
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| Reason for Leaving Hourly wage | ||||||||||
| No. 2 | ||||||||||
| Company: Dates: To Your Title: | ||||||||||
Address :
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| Immediate Supervisor's Name & Title: | ||||||||||
| Description of Duties |
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| Reason for Leaving Hourly wage | ||||||||||
| No. 3 | ||||||||||
| Company: Dates: To Your Title: | ||||||||||
Address :
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| Immediate Supervisor's Name & Title: | ||||||||||
| Description of Duties |
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| Reason for Leaving Hourly wage | ||||||||||
| If you have a resume to attach, do so here: (.doc, .rtf, .pdf or .txt files only) | ||||||||||
| Explain any gaps in the above mentioned employment dates: |
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| Education: |
Name & City/State |
Major or Degree |
Current Year |
Currently enrolled or will be? | If not in school, have you graduated? |
| High School | YesNo | YesNo | |||
| College or Vocational | YesNo | YesNo | |||
| Other | YesNo | YesNo |
| Licensures: * Nursing Assistants and Nurses – list all states that you held a license/certificate – even if it’s expired. * If required for this position, indicate License, Registration or Certification Information (Ex: NA, RN, LPN, etc.) |
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State(s) |
Number |
Expiration Date |
| Personal References Give the names and phone numbers of 3 individuals (not related to you, and not supervisors listed on your Work Experience & References) who have knowledge of your character, experience and ability. |
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| No. 1 | |
| Name | Phone |
| How long has this person known you? | |
| How does this person known you? | |
| No. 2 | |
| Name | Phone |
| How long has this person known you? | |
| How does this person known you? | |
| No. 3 | |
| Name | Phone |
| How long has this person known you? | |
| How does this person known you? | |
| Explain your reasons for seeking employment with Eventide, your qualifications for the position, and anything else you would like us to consider.: |
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AGREEMENT (Read Carefully) I certify that the information given on this application is, to the best of my knowledge, accurate and complete. I understand that false or misleading information given in my application or interview may be grounds for immediate disqualification as a candidate for employment or result in discharge of employment from Eventide. I understand that conditions may require me to work shifts other than the one for which I am applying and agree to such scheduling changes as directed by my Department Head. I agree that Eventide can change wages, benefits, and conditions at any time. I understand that any offer of employment is contingent upon passing a physical ability and health assessment and the completion of the company’s total pre-employment screening process which includes receiving references and background checks. I further understand that this is an application for employment and that no employment contract is being offered. I understand that if I am employed, such employment is at-will. Neither the employer nor I have agreed on any period of employment. I agree upon termination of employment that Eventide will not have any obligation to me, except to pay me for hours worked at the rate agreed upon. I have read and understood the paragraph above. I agree to the terms and conditions listed above. Name: Date: 05/25/2013 |
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INSTRUCTIONS TO APPLICANT: Please sign the following release, allowing Eventide to obtain
information relating to your activities from educational institutions, licensing agencies and all persons or entities
named on your employment application
AUTHORIZATION FOR RELEASE
OF REFERENCE INFORMATION Having made application for employment with Eventide, and desiring them to be informed as to my previous record and character, I hereby authorize Eventide and its authorized representatives to obtain information relating to my activities from educational institutions, licensing agencies and all persons or entities named on my employment application. This information may include, but is not limited to, academic, achievement, performance, attendance, personal history, and discipline and conviction records. I hereby direct you to release such information upon the request of the bearer and release from liability Eventide and its representatives for seeking such information. Further, I release any and all individuals and organizations, including record custodians, from any and all liability for damages of whatever kind or nature for furnishing said information. Name: Date: 05/25/2013 |
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AA/EEOC Compliance Form
Eventide is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights
laws and regulations. In order to comply with these laws, the employer invites applicants and employees to voluntarily selfidentify
their race and ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to
any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the
provisions of applicable laws, executive orders, and regulations, including those that require the information to be
summarized and reported to the federal and state government for civil rights enforcement. When reported, data will not
identify any specific individual.Name: Date: 05/25/2013 Position applied for SEX: Male Female ETHNICITY: Hispanic or Latino – If you check this box, you do not need to complete the RACE section I am of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race RACE (Not Hispanic or Latino): 2 or More Races I am one or more of the listed 5 races below. White I have origins in Europe, the Middle East, or North Africa Black or African American I have origins from any of the black racial groups of Africa Native Hawaiian or Other Pacific Islander I have origins from Hawaii, Guam, Samoa, or other Pacific Islands Asian I have origins from the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam American Indian or Alaska Native I have origins from North or South America (including Central America), and I maintain a tribal affiliation or community attachment with the tribe. DISABILITY: I consider myself a person with a disability I do not consider myself a person with a disability |