s/2 H d 1 PRINT_AREA s s$&%*^HEARTLAND CARE CENTER^620 E. 14TH AVENUE NE^DEVILS LAKE, ND 58301^701-662-4905!'APPLICATION FOR EMPLOYMENT ^PERSONAL 'Last Name  'First  'Middle  'Date'Street Address'Home Telephone'City, State, Zip'Business Telephone>'Have you ever been employed with Heartland Care Center?'Social Security #Z' Yes No If Yes: Month and Year_________Position________________'Position Desired'Pay ExpectedY'Apart from absence for religious observance, are you available for full-time work?''Will you work overtime if asked?Z' Yes No If not, what hours can you work?________________________D'Are you legally eligible for employment in the United States?!'When will you be available'to begin work?_________'Have you ever been convicted of a felony? Yes No (Conviction will not necessarily disqualify an >'applicant for employment) If yes, describe conditions:K'Other Special training or skills (languages, machine operation, etc)$"'SCHOOL MOST RECENTLY ATTENDED #'Name#'Address #'City #'State #'Phone%'Teacher or Counselor%'Department%'Last Grade Completed''Graduated''Now Enrolled''Sports or Activities+(' Yes No "(' Yes No,'PERSONAL REFERENCES-'1.) Name-'2.) Name-'3.) Name/' Address/' Address/' Address1' Telephone1' Telephone1' Telephone9'THREE MOST RECENT JOBS::'Company Name:'Telephone<'Address(<'Employed - (State month and year)&='From To>'Name of Supervisor>'Hourly wage%?'Beginning End-@'State Job Title and Describe Your Work@'Reason for leavingE'Company NameE'TelephoneG'Address(G'Employed - (State month and year)&H'From ToI'Name of SupervisorI'Hourly wage%J'Beginning End-K'State Job Title and Describe Your WorkK'Reason for leavingP'Company NameP'TelephoneR'Address(R'Employed - (State month and year)&S'From ToT'Name of SupervisorT'Hourly wage%U'Beginning End-V'State Job Title and Describe Your WorkV'Reason for leaving\'SIGNATUREu]'The information provided in this Application for Employment is true, correct and complete. If you employ me, [^'any misstatement of omission of fact on this application may result in my dismissal.o`'I understand that acceptance of an offer of employment creates no obligation upon you, the employer, to +a'continue to employ me in the future. d^Dated^Signatureh'INTERVIEWER'S REMARKS