Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Are you a citizen of the United States? *

Yes

No

If no, are you authorized to work in the United States?

Yes

No

Have you ever been convicted of a felony? *

Yes

No

Date available to start training:

MM

DD

YYYY

What positions/shifts are you interested in? *

Please select all that apply. Shift times may vary at each facility, times below are typical shifts.

Day Shift (7am-3pm)

Swing Shift (3pm-11pm)

Graveyard Shift (11pm-7am)

Weekend Day Shift (7am-7pm)

Weekend Graveyard Shift (7pm-7am)

Second on/Floating/PRN (Times vary)

RALF Administrator (Must have valid current RCA license)

Do you have a completed Health & Welfare Criminal History Unit Background check? *

Yes

No

If yes, has it been less than 3 years since it was completed?

Yes

No

If no, are you willing to obtain one before a job offer is presented to you?

Yes

No

If you have a Health & Welfare Criminal History Unit Background check, we are required to submit a Idaho State Police Background check. Are you willing to submit to this background check? *

Yes

No

Do you have a current Adult First Aid & CPR certification? *

Most certifications are only valid for 2 years

Yes

No

Do you have a valid certificate of Assisting with Medications? *

Yes

No

Have you completed any food handling courses? *

Yes

No