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INTERNAL EMPLOYMENT APPLICATION SOUTHVIEW ACRES HEALTH CARE CENTER 2000 OAKDALE AVENUE, WEST ST. PAUL, MN 55118 Tel: 651-554-9500 Fax: 651-451-9538 PLEASE PRINT IN INK, COMPLETING ALL INFORMATION Personal Information Date First Name Last Name Current Job Title Best Telephone Number Employed from month/year Current Supervisor Current Dept/Unit Current Position Desired Dept/Unit Desired Position Current Shift: AM PM NOC Desired Shift: AM PM NOC Current HRS Desired HRS Have you been in your Current Position for 90 days? No Yes Are you currently under any type of Performance and/or Attendance Improvement within the facility? No Yes NOTE: If you have not been in your current position for 90 days or are in a Performance and/or Attendance Improvement process, you are NOT eligible for a position change. Why do you believe you are the best candidate for this position? I certify, to the best of my knowledge, that all information given by me in this application is true and correct. I understand that false or misleading statements made by me or consequential omissions of any kind in the application process are sufficient cause for my not being hired or for my dismissal if I am already employed no matter when discovered. I understand that if hired, my employment is not for any definite period of time or successions of periods, is not governed by any written or oral contract, and is considered an “at-will” arrangement. This means that either Southview Acres or I am free to terminate my employment at any time for any reason, so long as there is no violation of applicable law. Signature Date RETURN THIS APPLICATION TO SCHEDULING (FOR NURSING) OR THE DIRECTOR OF THE DEPARTMENT (OTHER THAN NURSING). EMPLOYER USE ONLY RECEIVED _______/_______/ _______ BY: ____________ IS THE SHIFT AVAILABLE? : YES NO COPY TO __________ (CURRENT MANAGER) ON _______/_______/ _______ YES NO, Why? _____________________________________________________________________________ COPY TO __________ (PROSPECTIVE MANAGER) ON _______/_______/ _______ YES NO, Why? _____________________________________________________________________________ Employee Notified: _______/_______/ _______ HR Southview Acres Health Care Center is an AA/EEO employer. Revised by: MC 8/1/13