Spiritual Care Volunteer Services Employment Request Campus Information Locations Privacy Policy
Good Shepherd Community:
Where Seniority Has Its Privileges.
PERSONAL INFORMATION
First Name:
Last Name:
Middle Name:
Street Address:

City:
State:
Zip:
Email:
Home Phone:
Alternate Phone:
Social Security Number:
Have you ever been convicted of abuse, neglect, or mistreatment of any individual(s)? Yes No
If "Yes", please explain:
Have you ever applied for employment with Good Shepherd? Yes No
If "Yes", when and what position?
Have you ever worked for Good Shepherd? Yes No
If "Yes", when and what position?
If hired, can you provide verification of your legal right to work in the United States? Yes No
Are you at least 18 years of age? Yes No
EMPLOYMENT INTERESTS
Position Desired:
Location:  
Salary Desired:
Date available to begin work:
Type of employment desired: Full-Time

Part-Time

On-call

Seasonal

Other:
Are you available to work: Days

Evenings

Nights

Weekends

Holidays

Rotation
Number of hours desired per week:
How were you referred to our company? Ad
(Where)

Employee Referral
(Name)

Walk-in

Agency
(Name)

Other
(Please specify)
EDUCATION INFORMATION
High School
Name and Location of School:
Course of Study:
Did you graduate? Yes No
Degree or Diploma?
College/University
Name and Location of School:
Course of Study:
Did you graduate? Yes No
Degree or Diploma?
College/University
Name and Location of School:
Course of Study:
Did you graduate? Yes No
Degree or Diploma?
College/University
Name and Location of School:
Course of Study:
Did you graduate? Yes No
Degree or Diploma?
College/University
Name and Location of School:
Course of Study:
Did you graduate? Yes No
Degree or Diploma?
Please include any other information you think would be helpful to us in considering you for employment, such as activities, volunteer experiences, accomplishments, ect. (Please exclude all information indicitive of age, sex, race, religion, color, national origin and handicap.)

PROFESSIONAL LICENSES AND/OR CERTIFICATES
LPN
State Issued:
Expiration Date:
License Number:
RN
State Issued:
Expiration Date:
License Number:
CNA
State Issued:
Expiration Date:
Are you on the registry? Yes No
Home Health Aide
Home Health Certification: Yes No
State Issued:

Driver's License Number:
Do you hold a MN CDL Class B License? Yes No
Cosmetologist License Number:
Social Worker License Number:
Boiler's / Engineer (1st Class grade C) License Number:
Business Machines
You Can Operate:
Computer

10-key

Switchboard

Typing Speed:
Words per minute with
errors
Please List any computer programs you have experience with:
EMPLOYMENT INFORMATION
(start with most current employer)
Account for all time periods including unemployment, self-employment and military service.
1.
Company Name:
Company Phone:
Time Employed: From Mo./Yr.

To Mo. / Yr.
Street Address:
City:
State:
Zip:
Pay: Starting $

Ending $
Job Title:
Duties:
Supervisors Name:
Reason for Leaving:
May we contact this employer? Yes No
If "No", why?
2.
Company Name:
Company Phone:
Time Employed: From Mo./Yr.

To Mo. / Yr.
Street Address:
City:
State:
Zip:
Pay: Starting $

Ending $
Job Title:
Duties:
Supervisors Name:
Reason for Leaving:
May we contact this employer? Yes No
If "No", why?
3.
Company Name:
Company Phone:
Time Employed: From Mo./Yr.

To Mo. / Yr.
Street Address:
City:
State:
Zip:
Pay: Starting $

Ending $
Job Title:
Duties:
Supervisors Name:
Reason for Leaving:
May we contact this employer? Yes No
If "No", why?
4.
Company Name:
Company Phone:
Time Employed: From Mo./Yr.

To Mo. / Yr.
Street Address:
City:
State:
Zip:
Pay: Starting $

Ending $
Job Title:
Duties:
Supervisors Name:
Reason for Leaving:
May we contact this employer? Yes No
If "No", why?
REFERENCES
Please list three personal references below. (Do not include previous supervisors or relatives)
1.
Name:
Relationship:
Phone:
2.
Name:
Relationship:
Phone:
3.
Name:
Relationship:
Phone:
Applicant's Statement of Agreement
Please read carefully and sign below

I authorize any person, school, current employer (except as expressly noted), past employer(s), and organizations named in this application form (and accompanying resume or other documentation, if any) to provide Good Shepherd with relevant information and opinion, personal or otherwise, that may be useful in making a hiring decision. I release all parties from all liability for any damage that may result from furnishing information and opinion to you.

In consideration of employment, I agree to obey the rules and standards of Good Shepherd. I understand that nothing contained in this application or in the interview process is intended to create a contract between Good Shepherd and myself for either employment or for the providing of any benefits. I agree that my employment is at-will and the terms of employment may be changed with or without cause, with or without notice, including but not limited to termination, demotion, promotion, transfer, compensation, benefits, duties and location of work, at any time, for any reason, at the option of myself or Good Shepherd. This constitutes my entire agreement with Good Shepherd with regard to the length of my employment.

I understand that emergency conditions or staffing needs 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 supervisor or department head of Good Shepherd.

I hereby acknowledge that I have read the above statements and understand them. I certify that I, the undersigned applicant, have personally completed this application. I declare that the facts contained in the application (or any resume or other documents submitted) are true and complete to the best of my knowledge. I understand that any misrepresentations or omissions will disqualify me from further consideration for employment, and will result in my dismissal from employment, if discovered at a later date.
Digital Signature:
Good Shepherd is an equal opportunity employer (EOE). We are dedicated to a policy of nondiscrimination in employment on any basis, including race, color, age, sex, religion, national origin, disability, veteran status, citizenship status, status in regards to public assistance, sexual orientation, member or activity in a local commission, marital status, or any other protected class. We assure you that your opportunity for employment with this employer depends solely upon your qualifications.

Application will remain active for 90 days.
Thank you for your interest in Good Shepherd.



GOOD SHEPHERD
AFFIRMATIVE ACTION SURVEY
 An Equal Opportunity, Affirmative Action Employer
PLEASE READ CAREFULLY

Applicants are considered for all positions and employees are treated equitably during their employment without regard to their race, color, creed, religion, sex, national origin, age, marital status, affectional preference, disability, military status or status with regard to source of income.

As an employer taking affirmative action to ensure the removal of any possible discrimination and to help comply with governmental record-keeping requirements, we would appreciate your completing this form. However, COMPLETION OF THIS FORM IS STRICTLY VOLUNTARY. The data will be physically separated from the remainder of your job application before the application is considered for possible employment. This information will be kept in a confidential file SEPARATE FROM YOUR APPLICATION FOR EMPLOYMENT. Failure to supply this information will not jeopardize or adversely affect any consideration you may receive for employment, or later advancement in employment.
Position(s) Applied For:
First Name:
Last Name:
Middle Initial:
Phone:
Street Address:

City:
State:
Zip:
Social Security #:
Gender: Male Female
How were you referred to the Good Shepherd community? Newspaper Ad:

College/Technical
(Name):

Employee/Former Employee
Referral:

Walk-in

Community Agency Referral:

Minnesota Job Service
(Name)

Other:
(Please describe)
Race/Ethnic Group: White (not Hispanic or Latino) - persons having origins in any of the original people of Europe, North Africa, or the Middle East.

Black or African American (not Hispanic or Latino) - persons having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander (not Hispanic or Latino) - persons having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Asian (not Hispanic or Latino)- persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example: Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

American Indian or Alaska Native (not Hispanic or Latino) - persons having origins in any of the original people of North and South America (including Central America), and who maintain tribal affiliation or community attachment.

Hispanic or Latino - persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.

Two or More Races (Not Hispanic or Latino) – All persons who identify with more than one of the above five races.
Disability Status
Are you a person with a disability?		 Yes No
Veteran Status
Are you a disabled veteran?		 Yes No
Are you a Vietnam Era Veteran? Yes No
Please fill in the letters as they appear on the right
* This form is not used for employment decisions. If you have a disability and need an accommodation so that you can perform the duties of the job for which you are applying, please notify us in some other manner.