Valley View Healthcare and Rehab
510 East Cedar Street
Houston, Minnesota 55943
Call Us Today! 507.896.3125
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Part-Time Staff Nurse (LPN)
Part-Time Registered Nurse (RN)
RN, Assistant Director of Nursing
Must be a Licensed Registered Nurse (RN)
Must have a minimum 3 years nursing experience
Full job description available upon request.
Application For Employment
Date Of Application
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Date Available
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Name
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First
Last
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Email
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Present Address
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City
State
Zip Code
Country
Phone Number
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Permanent Address (If different than Present Address)
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Line 1
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City
State
Zip Code
Country
Phone Number
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If you cannot be reached at above phone number, where may we contact you?
Name Of Person
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First
Last
Phone Number
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Employment Desired
First Choice
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Shift Choice #1
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Salary Desired
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Second Choice
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Shift Choice #2
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Salary Desired #2
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Third Choice
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Shift Choice #3
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Salary Desired #3
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Will You Accept Employment:
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Full Time
Part Time
Temporary
Are Yo 18 yrs. of Age or Older?
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Yes
No
Are You Employed Now?
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Yes
No
May We Contact Your Present Employer?
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Yes
No
How Did You Learn Of This Opening?
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Education
Enter Highest Grade Completed
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Scholastic Honors Recevied
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Grammar or Grade School
Name Of School
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City, State
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Courses Taken
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Completed
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No
Type of Degree or Certificate Received
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High School
Name Of School
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City, State
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Courses Taken
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Completed
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No
Type of Degree or Certificate Received
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College
Name Of School
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Courses Taken
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Completed
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No
Type of Degree or Certificate Received
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Vocational or Business
Name Of School
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Courses Taken
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Completed
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No
Type of Degree or Certificate Received
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Professional Education
Name Of School
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Courses Taken
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Completed
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Yes
No
Type of Degree or Certificate Received
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Laboratory or X-Ray Training
Name Of School
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City, State
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Courses Taken
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Completed
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Yes
No
Type of Degree or Certificate Received
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Extracurricular Activities While in School
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Member of Professional Organizations
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Honors Received, Volunteer or Community Service or Other Qualifications You Have Which You Feel Are Related to the Position for Which You Are Applying
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Are you in the U.S. Armed Forces
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Yes
No
If yes, what branch?
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Date of Duty From
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Date of Duty To
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Rank at Discharge
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Professional Licenses and/or Certifications
Type
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Organization or State Issued
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Date Issued
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Number
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Type
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Organization or State Issued
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Date Issued
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Number
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Type
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Organization or State Issued
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Date Issued
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Number
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Employment Understanding (Please Read and Agree)
It is the policy of Valley View Nursing Home of Houston, inc. to provide equal opportunity to all employees and applicants for employment in the administration of personnel practices such as recruitment, hiring, promotions, and all other conditions and privileges of employment. The facility does not discriminate on the basis of race, color, creed, ancestry, national origin, martial status, liability for service in the Armed Forces of the United States, sex, age, handicap (except where sex, age, or physical condition is a bonafide occupational qualification), sexual orientation, religion, status with regard to Public Assistance, or any other protected class required by Federal/State/Local law.
I voluntarily give the institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility of all persons, companies or corporations supplying such information. I consent to take the physical examination and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination which relates to the essential job duties I would be required to perform.
I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.
If employed, I will be required to complete and Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.
Do You Agree or Disagree
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Agree
Disagree
Please Indicate Days and Hours You Are Available For Work (Be Specifc)
Sunday From
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Sunday To
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Monday From
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Monday To
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Tuesday From
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Tuesday To
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Wednesday From
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Wednesday To
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Thursday From
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Thursday To
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Friday From
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Friday To
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Saturday From
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Saturday To
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Availability Record
Primary Position Desired
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Will you accept another position?
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Yes
No
If so, What?
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Do you limit your annual earnings due to Social Security or other reasons?
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Yes
No
If yes, please state what is the maximum amount you wish to earn
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If your availability changes, it is your responsibility to fill in an "Availability Care" indicating the changes. Such changes will be effective, then, for any future employment.
I understand that emergency conditions may require me to temporarily work shifts other than the one for which I am applying and agree to such scheduling change as directed by my department head or administrator of this institution.
I comply
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Yes
No
Dear Applicant
Valley View Nursing Home, an affirmative action/equal opportunity employer, is required to compile statistics on the race/ethnicity, sex and disability of all applicants. This information will be used to monitor the facilities' progress with its equal opportunity and affirmative action programs. Providing the information requested on this letter is
strictly volunary.
It is kept confidential and will not be used in any way to evalute your qualifications for employment.
Title of Position
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Name
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First
Last
Gender
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Male
Female
Disability
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Yes
No
Race/Ethnicity
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White, Non-Hispanic
Black, Non-Hispanic
Hispanic
Asian or Pacific Islander
Native American or Alaskan Native
How did you find out about the position?
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Submit