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Employment Application

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PERSONAL INFORMATION
First*
Middle
Last*
Maiden Name (if applicable)
Other and/or Previous Names Used (if applicable)
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Are you at least 18 years of age?
- Yes
- No
Which position are you applying for?
If you are applying for CNA, LPN, or RN-
Professional License Number*
If you DO NOT have a professional license number, please enter: 00000
License Type
Have you ever been employed with RCCC?*
- Yes
- No
If yes, when?
Have you ever held a license in another state? (CNA, LPN, or RN)*
- Yes
- No
If yes, where?
Are you authorized to work for wages in the United States?*
- Yes
- No
If you answered "Yes", you will be required to present documentation showing your employment authorization and identity.
Have you ever been employed in another state?*
- Yes
- No
If yes, where?
Have you been convicted of a criminal offense within the last (7) years?*
- Yes
- No
If yes, please explain:
Do we have your authorization to perform a background check?*
- Yes
- No

EMPLOYMENT DESIRED
Position You Are Applying For
Shift(s) You Can Work
- Days
- Evenings
- Nights
- Any
Date you can start
Type of Work
- Full Time
- Part Time
EDUCATION
Highest level of education you have completed?
Name of last school attended?
Degree attained?
Vocational or trade training?

REFERENCES
List below three people not related to you.
REFERENCE #1
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email
In what capacity do you know this person?
REFERENCE #2
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email
In what capacity do you know this person?
REFERENCE #3
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email
In what capacity do you know this person?

WORK EXPERIENCE
List below your work experience, starting with your present or last place of employment.
EMPLOYMENT #1
Dates of Employment
Start Date
End Date
End Date
Name of Company
Address
Street Address Address Line 2 City State ZIP Code
Phone
Supervisor's Name
Position Held
Reason for Leaving
EMPLOYMENT #2
Dates of Employment
Start Date
End Date
End Date
Name of Company
Address
Street Address Address Line 2 City State ZIP Code
Phone
Supervisor's Name
Position Held
Reason for Leaving
EMPLOYMENT #3
Dates of Employment
Start Date
End Date
End Date
Name of Company
Address
Street Address Address Line 2 City State ZIP Code
Phone
Supervisor's Name
Position Held
Reason for Leaving
Information for Government Monitoring Purposes
The following information is requested by the Federal Government in order to monitor compliance with applicable Federal Civil Rights laws. The law states that a provider of services may neither discriminate on the bases of this information, nor on whether you choose to furnish it. However, if you choose not to furnish it, under Federal regulations, the provider of services is required to note race, ethnicity, and sex on the basis of visual observation or surname.
I do not wish to furnish this information
Date:
Ethnicity
- Not Hispanic or Latino
- Hispanic or Latino
Mark One
Race
- White
- Black or African American
- American Indian/Alaskan Native
- Asian
- Native Hawaiian or Other Pacific Islander
- Some Other Race
- Two or More Races
Mark one or more
Sex
- Female
- Male
Resume
Accepted file types: onlyacceptspdfs, Max. file size: 50 MB.
Please attach your resume here.

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Rolette Community Care Center

Location

804 State Street

Rolette, ND 58366

Contact

Tel 701-246-3786
Fax 701-246-3422

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