Job Application: Director of Nursing: Full-time

APPLICATION FOR EMPLOYMENT for: Sisters of St Francis of Colorado Springs, Inc.,7665 Assisi Heights Colorado Springs, CO 80919 and its Ministries: St Francis Nursing Center, Inc., (d.b.a. Mount Saint Francis Nursing Center), Franciscan Community Counseling, Inc., and Franciscan Retreat Center, Inc. All Ministries are Equal Opportunity Employers. We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, genetic information or any other status protected by law or regulation. It is our intention that all qualified applicants are given equal opportunity and that selection decisions be based on job related factors. Answer each question fully and accurately. No action can be taken on this application until you have answered all questions.

Title: Director of Nursing: Full-time

Fields marked with an asterisk (*) must be filled out before submitting.

GENERAL

What type of employment are you seeking?	Full-Time Part-Time PRN Day Shift Evening Shift Night Shift
Last Name *
First Name *
Middle Name
Telephone Number *
Email Address
Present Street Address *
City *
State *
Zip Code *
Are you 18 years of age or older?	Yes No

(If you are hired,you may be required to submit proof of age)

If hired,can you furnish proof you are eligible to work in the U.S.?	Yes No
Have you ever applied here before?	Yes No
If yes,when?
Were you ever employed here?	Yes No
If yes,when?
Do you have any relatives working for Sisters of St Francis or one of its Ministries?	Yes No
If Yes,please give details
Have you ever been convicted of any law violation? Include any plea of guilty or no contest. Exclude minor traffic violations	Yes No
If yes,give details. (A conviction will not necessarily disqualify an applicant for employment)
Have you had your drivers license suspended or revoked in the last 3 years?	Yes No
If yes,give details
If employed,do you expect to be engaged in any additional business or employment outside of our job?	Yes No
If yes,give details
For Driving Jobs ONLY:Do you have a valid drivers license?	Yes No
Drivers License Number
Class of License
State Licensed In
List professional, trade, business or civic activities and offices held. (Exclude labor organizations and memberships which reveal race, color, religion, national origin, sex, age, disability, genetic information or other protected status.)
RN/LPN/CNA License Number
State
Name as it appears on Professional License/Certification

Education

List Names and Addresses of Schools Attended

High School or GED
Number of Years Completed	1 2 3 4
Diploma	High School Diploma GED
College or University
Number of Years Completed	1 2 3 4 5 6 or More
Diploma/Degree/Certificate	Certificate Associate’s Degree Bachelor’s Degree Master’s Degree Doctoral Degree Professional Degree
Subjects Studied
Vocational or Technical
Number of Years Completed	1 2 3 4
Diploma/Degree/Certificate	Certificate Associate’s Degree Bachelor’s Degree
Subjects Studied
What skills or additional training do you have that relate to the job for which you are applying?
What machines or equipment can you operate that relate to the job for which you are applying?

Work History

List work history by most recent employment first. Account for all periods of time including military service and any periods of unemployment. Note:A job offer may be contingent upon acceptable references from current and former employers.

Name of Employer
Address
City,State,Zip Code
Supervisor(s)
Telephone
Job Title
Duties

Dates of Employment

From:
To:
Pay Rate $
Reason for Leaving
Name of Employer
Address
City, State, Zip Code
Supervisor(s)
Telephone
Job Title
Duties

Dates of Employment

From:
To:
Pay Rate $
Reason for Leaving
Name of Employer
Address
City,State, Zip Code
Supervisor(s)
Telephone
Job Title
Duties

Dates of Employment

From:
To:
Pay Rate $
Reason for Leaving
Name of Employer
Address
City,State,Zip Code
Supervisor(s)
Telephone
Job Title
Duties

Dates of Employment

From:
To:
Pay Rate $
Reason for Leaving

References

Have you worked or attended school under any other names?	Yes No
If yes,give names
Are you presently employed?	Yes No
If yes,whom do you suggest we contact?
Have you ever been fired from a job or asked to resign?	Yes No
If yes,please explain

Give three references, not relatives or former employers

Reference #1
Address
Phone
Reference #2
Address
Phone
Reference #3
Address
Phone
Have you seen or reviewed a job description?	Yes No
Do you understand the job requirements?	Yes No
Can you perform the job requirements with or without reasonable accommodation?	Yes No
Please let us know how you heard about this position?	Indeed.com Craigslist.org Monster.com Center for Non-Profit Excellence Mt. St. Francis Website Other (choose button below)
	A friend, family member Professional associate Through a job fair or article Newspaper ad
Please enter Name or Source
OPTIONAL Upload your Resume

PLEASE READ EACH STATEMENT CAREFULLY BEFORE SUBMITTING APPLICATION. I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I authorize the investigation of any or all statements contained in this application. I also authorize, whether listed or not, any person, school, current employer, past employers, and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements. I hereby consent to a pre- and/or post-employment drug screen as a condition of employment, if required. I understand that if I am extended an offer of employment it may be conditional upon my successfully passing a Tuberculin (PPD) skin test and a background screening.I UNDERSTAND THAT THIS APPLICATION, ANY VERBAL STATEMENTS BY MANAGEMENT OR SUBSEQUENT EMPLOYMENT, DO NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. I UNDERSTAND EMPLOYMENT WITH A MOUNT ST FRANCIS MINISTRY IS AT-WILL AND MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASON, AND WITH OR WITHOUT NOTICE. I have read, understand, and by submitting my application, I consent to these statements.