Employment Application

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Employment Application

We thank you in advance for your interest in becoming part of our growing team of professionals.

Personal Information

Full Name *

Address *

Phone *

Email *

Are you at least 18 years of age? *

Professional License Number *

License Type *

If you are not a US citizen, do you have the legal right to remain permanently and work in the US? *

Employment Desired

Position you are applying for *

Shifts you can work *

Date you can start *

Type of work desired *

Education

Highest level of education you have completed?

Name of last school attended?

Degree attained?

Type of Training

References

Reference #1 Name

Reference #1 Address

Reference #1 Phone

Reference #1 Email

Reference #1 In what capacity do you know this person?

Reference #2 Name:

Reference #2 Address:

Reference #2 Phone

Reference #2 Email:

Reference #2 In what capacity do you know this person?

Reference #3 Name:

Reference #3 Address

Reference #3 Phone:

Reference #3 Email:

Reference #3 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

Employment #1 Start Date/End Date

Employment #1 Name of Company

Employment #1 Company Address

Employment #1 Company Phone:

Employment #1 Supervisors Name:

Employment #1 Position Held

Employment #1 Reason for Leaving:

Employment #2

Employment #2 Start Date/End Date

Employment #2 Name of Company:

Employment #2 Company Address:

Employment #2 Company Phone:

Employment #2 Supervisors Name:

Employment #2 Position Held:

Employment #2 Reason for Leaving:

Employment #3

Employment #3 Start Date/End Date

Employment #3 Name of Company:

Employment #3 Company Address:

Employment #3 Company Phone:

Employment #3 Supervisors Name:

Employment #3 Position Held:

Employment #3 Reason for Leaving:

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Buffalo Lake Healthcare Center

Address
703 West Yellowstone Trail
Buffalo Lake, MN 55314

Phone
(320) 833-5364

Fax
(320) 833-5526

Email
info@blhcc.org

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