Employment

As of 9/10/19 we have the following open positions:

• Dietary Aide/Cook – PT

• Certified Nursing Assistant – FT, day shift and

FT evening shift

• Evening Nurse – FT

Date of Application:

Full Name:

Address, City, State and Zip:

Required

Phone Number:

Cell Number:

Type of Work Desired?

What Shift Would You Prefer to Work?

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What Salary Range Would You Like?

Will You Accept Employment of Full Time, Part Time or Temporary?:

Are You 18 Years of Age or Older? Yes or No?

Required

Are you Employed Now? Yes or No?

Required

May We Contact Your Present Employer? Yes or No?

Required

How Did You Learn of This Opening?

What is The Highest Grade of School You Completed? 9, 10, 11, 12, 13, 14, 15, 16?

Required

Scholastic Honors Received?:

Name of College, Location, Courses Taken, Did You Complete Your Education and What Type of Degree or Certificate Did You Receive? Date Completed?

Name of Vocational or Business School, Location, Courses Taken, Did You Complete Your Education and What Type of Degree or Certificate Did You Receive? Date Completed?

Name of Professional Education School, Location, Courses Taken, Did You Complete Your Education and What Type of Degree or Certificate Did You Receive? Date Completed?

Name of Laboratory or X-Ray Training, Location, Courses Taken, Did You Complete Your Education and What Type of Degree or Certificate Did You Receive? Date Completed?

Extracurricular Activities While in School?

Member of Professional Organizations:

Honors Received. Volunteer or Community Service or Other Qualifications You Have Which You Feel Are Related to the Position for Which You Are Applying:

Were You In the U.S. Armed Forces? Yes or No? If Yes, What Branch?

Required

Dates of Duty: From What Date to What Date?

Required

Rank at Discharge:

What Professional Licenses and/or Certificates Do You Have: Type, Organization or State Issued, Date Issued, Number

Required

What Professional Licenses and/or Certificates Do You Have: Type, Organization or State Issued, Date Issued, Number

Required

What Professional Licenses and/or Certificates Do You Have: Type, Organization or State Issued, Date Issued, Number

Required

Image Verification:

Required

Date Available:

Name of High School, Location, Courses Taken, Did You Complete Your Education and What Type of Degree or Certificate Did You Receive?

501 4th Street, Wilmot, SD 57279 605-938-4418 administrator@wilmotcarecenter.com