South Central Nebraska Southeast South Dakota
2222 2nd Ave, Ste 700
P.O. Box 368
Kearney, NE 68848-0386
Ph: 308-234-4663
Toll Free 866-234-6466		 25 W Main St
P.O. Box 503
Vermillion, SD 57069-0503
Ph: 605-624-5900
Toll Free 877-624-5900

This form is to be completed online. For a printed application, please go to this link: application

Application for Employment

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including race, color, age, sex, religion, disability, medical condition, national origin, or marital status.

All fields marked with an asterisk (*) are REQUIRED before the form can be submitted.

*Application Request for:
   Kearney, Nebraska      Vermillion, South Dakota
*Name:
 *Date:
 *How did you hear about this employment opportunity?
*Street Address:
*City:
 *State:
 *Zip Code:
*Phone:
 *E-mail:
 *Social Security Number:
 
Emergency Contact:
Name:
 Phone:
Address:
 Relationship:
 
*I am applying for a position as a
Home Health Aide   Homemaker/Companion Aide		 I am currently: a CNA
YES       NO		 a Medication Aide
YES       NO
Have you ever been convicted of a felony or theft?
YES       NO
If yes, please provide details:
 
Transportation:
Many caregiver positions require the caregiver to transport a client.
*Do you have dependable transportation?
YES       NO		 Make and model of car:
License plate #
 Driver license #
 Auto insurance policy #
Insurance Company
 Insurance agent name
 Insurance agent phone
 
Availability:
Number of hours you would like to work
 Times you are available to work
 Any times not available to work
 Can you be called at the last minute in case of emergency?
YES      NO
Comments:
 
Education:
High School
 City/State
 Dates
College
 City/State
 Dates
Other
 City/State
 Dates
Degrees/certificates
Special skills or courses
 
Experience:
Discuss any training or experience working with the elderly
What would you like most about working with the elderly?
What would you like least about working with the elderly?
 
Skills:
Please indicate whether you have assisted with or performed the following tasks for the elderly. If you have not done these tasks before but are willing to perform these tasks, please mark WT.
Companionship yes   WT   no
Bathing Assistance yes   WT   no
Grooming yes   WT   no
Incontinence Care yes   WT   no
Transfer Assist yes   WT   no
Dressing Assistance yes   WT   no
Vacuuming yes   WT   no
Dusting yes   WT   no
Clean Bathroom yes   WT   no
Clean Kitchen yes   WT   no
Change Bed Linen yes   WT   no
Organize Spaces yes   WT   no
Laundry yes   WT   no
Pet Care yes   WT   no
Cooking yes   WT   no
Driving yes   WT   no
Grocery Shopping yes   WT   no
Medication Reminders yes   WT   no
 
Employment History:
Start with your current / most recent employment and work backwards. Please go back at least five years and include all previous experiences working with the elderly.
May we contact your current employer?
YES      NO
Company
 From
 To
Job title
 Reason left
Duties
Supervisor
 Phone
Company
 From
 To
Job title
 Reason left
Duties
Supervisor
 Phone
Company
 From
 To
Job title
 Reason left
Duties
Supervisor
 Phone
Company
 From
 To
Job title
 Reason left
Duties
Supervisor
 Phone
 
Business References:
These are people you have worked with in a professional manner: co-workers, community projects, etc.
Name
 Address
 Relationship/Years Known
 Local Phone #
Name
 Address
 Relationship/Years Known
 Local Phone #
Name
 Address
 Relationship/Years Known
 Local Phone #
Name
 Address
 Relationship/Years Known
 Local Phone #
Name
 Address
 Relationship/Years Known
 Local Phone #
 
Personal References:
These are your family members, friends, neighbors, etc.
Name
 Address
 Relationship/Years Known
 Local Phone #
Name
 Address
 Relationship/Years Known
 Local Phone #
Name
 Address
 Relationship/Years Known
 Local Phone #
Name
 Address
 Relationship/Years Known
 Local Phone #
Name
 Address
 Relationship/Years Known
 Local Phone #
 
CERTIFICATION AND RELEASE: I certify that I have read and understand the application note at the top of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
*I agree with the above statement.    *Signature
 *Date