Please enable JavaScript in your browser to complete this form. - Step 1 of 7Name *FirstLastEmail *Phone *Address *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDesired Position *Date Available to Start *Shift Availability *6am - 2:30pm2pm - 10:30pm10pm - 6:30amOtherAre you interested in a full-time or part-time position? *Full TimePart TimeDesired Salary *Have you worked for West Ridge in the past? *YesNoIf yes, when?Upload your resume (if applicable) Click or drag a file to this area to upload. NextEducationHigh SchoolName of SchoolYears AttendedDid you graduate?YesNoCollegeName of SchoolYears AttendedDid you graduate?YesNoDegreeOther EducationName of SchoolYears AttendedDid you graduate?YesNoDegree NextPrevious EmploymentCompanyPositionPhoneFromToReason for LeavingMay we contact your previous supervisor for a reference?YesNoCompanyPositionFromToReason for LeavingMay we contact your previous supervisor for a reference?YesNoCompanyPositionFromToReason for LeavingMay we contact your previous supervisor for a reference?YesNoNextReferencesPlease provide three professional references.Name *CompanyRelationshipPhoneName *CompanyRelationshipPhoneName *CompanyRelationshipPhoneNextEmployee WaiverI, the undersigned hereby give my permission for West Ridge Care Center of Cedar Rapids, Iowa to conduct a criminal history and dependent adult abuse check with the division of Criminal Investigation. I also give permission for West Ridge Care Center to conduct an OIG exclusion list check that is maintained by the Attorney General's office of the United States. I further understand that my future employment with West Ridge is, in part dependent upon the results of this record check.Legal Name *FirstMiddleLastMaiden NameDate of BirthGenderMaleFemaleState License NumberProfessional License TypeProfessional License NumberSocial Security Number *Pursuant to federal law, health care providers are prohibited from employing individuals who have been placed on the OIG Exclusion List maintained by the Attorney General's Office of the United States. Employers have a continued obligation to periodically check weather employees have been placed on these lists and must maintain current information regarding the identification of their employees.Have you ever been known by another legal last name?YesNoIf yes, please list ALL other last names:Do you go by a different first name other than your legal name?YesNoIf yes, please list ALL other first names:Do you have knowledge of being placed on the OIG Exclusion list?YesNoIf yes, please explain when and why you were on the list:Previous Address, City and StateI certify that the above information provided is true and complete to the best of my knowledge. I understand that the Facility might investigate all statements made in this document and that any false or misleading information I have provided can result in a decision to immediately discharge or lead to civil or criminal penalties as appropriate.Signature *Clear SignatureNextDisclaimer & SignatureI certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.Signature *Clear SignatureNextInformation Regarding Child and Dependent Adult AbuseDo you have a record of founded child or dependent adult abuse? *NoYesI am applying for a position with West Ridge Care Center. I understand that, according to Iowa law, a record check can be made regarding any instance of child abuse or dependent adult abuse in which I have been involved. I hold West Ridge Care Center free from any recourse as a result of this mandated record check.Signature *Clear SignatureNameSubmit