Human Resources Department

Application for Employment

Complete the form below to apply. All fields marked with * are required.

Personal Information

Full name *

Date of application *

Street address

Apt / Suite

City

State

ZIP code

Phone number *

Email address *

Desired Employment & Shifts

Position applied for *

Date available to start

Desired pay rate ($/hr)

Employment type desired *

Shift availability (check all that apply)

Education & Professional Credentials

School / Institution

Degree / Certificate

Grad year

License type

License / Registry number

Expiration date

Employment History

Most recent employer

Company name

Job title

Dates (MM/YY - MM/YY)

City, State

Supervisor name & phone

Reason for leaving

Description of core duties

MN Licensure Background Screening Acknowledgement

Pursuant to Minnesota Statute 144G, all individuals seeking employment in a licensed assisted living facility must undergo a background study managed by the Department of Human Services via NETStudy 2.0. Employment is strictly conditional until a "Cleared" status is received.

I acknowledge and authorize the required Minnesota DHS background screening process. *

Applicant electronic signature *

Date signed *

Do not submit medical, SSN, or other sensitive PHI through this form.