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Coburg Village Employment Application

You must complete and submit your application in one session and answer all required questions in order to submit your online application. Your answers will not be stored in the form.

You will receive a confirmation email when your application is successfully submitted.

We are an Equal Opportunity Employer

We do not discriminate on the basis of actual or perceived race, religion, sex, age, national origin, sexual preference, disability, or any other status protected under Federal, State, or local laws and regulations. The Lutheran Care Network (TLCN) is committed to the policy of equal employment opportunity in recruitment, hiring, career advancement, and all other employment practices.

Personal Information

Last Name: (Required)

First Name: (Required)

Middle Name

Position for which you are applying: (Required)

Salary/Hourly Rate Requirements:

How did you hear about this opening ?

Days and Hours Preferred:

Date Available for Employment: (Required)

Your Email Address: (Required)

Your Address:

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Phone Number: (Required)

Cell Phone
Home phone

Are you 18 years of age or older?

If no, what is your age?

Are you legally authorized to work in the U.S.?

Will you be able to provide proof within three days of employment?

Are you related to an officer or employee of Coburg Village or The Lutheran Care Network?

If yes, what is their name?:

First and Last Name

First Name

Last Name

Name of Facility

Position held and location:

Were you previously employed by Coburg Village or the Lutheran Care Network?

If yes, indicate facility name:

Indicate dates employed:

Education

Name of High School or Equivalency and location: (Required)

Diploma or Degree Received:

Type of Diploma or Degree Received:

Major Subject:

Undergraduate Name of School and Location:

Diploma or Degree Received:

Major Subject:

Graduate School Name and Location:

Diploma or Degree Received:

Major Subject:

Name and location Post Graduate, Professional, Business, Other:

Diploma or Degree received

Type of Degree or Certificate received

Program of Study Now Being Taken:

Academic Honors or Recognition Received:

Extracurricular Activities or Interests:

Foreign Languages

Foreign Languages:

Professional or Honorary Societies or Organization Memberships:

Special Skills/ Qualifications:

Licenses and/or Certifications

Licenses and/or certifications

Issuing State

Issuing Agency

License/Certificate Number

Date of Original Licensure/Certification :

Expiration Date:

Employment History

Name of Present or Last Employer:

Dates of Employment:

Position Held:

Status

FT
PT
Per Diem

Description of Duties:

Nature of Business:

Address:

Country

Address Line 1

City

State/Province

Postal Code

Telephone Number (please include area code)

Reason for leaving:

Number and type of employees supervised, if any:

Name of Employer

Dates of Employment:

Position Held:

Status

FT
PT
Per Diem

Description of Duties:

Nature of the Business:

Address:

Country

Address Line 1

City

State/Province

Postal Code

Telephone Number:

Reason for leaving:

Name of Employer:

Dates of Employment:

Position Held:

FT
PT
Per Diem

Description of Duties:

Nature of Business:

Address:

Country

Address Line 1

City

State/Province

Postal Code

Telephone Number:

Reason for Desired Change or Leaving:

Professional References

#1 Name

First Name *

Last Name *

Address:

Country

Address Line 1

City

State/Province

Postal Code

Phone: (Required)

Years Known: (Required)

Description:

#2 Name:

First Name *

Last Name *

Address:

Country

Address Line 1

City

State/Province

Postal Code

Phone: (Required)

Years Known: (Required)

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Description:

#3 Name

First Name *

Last Name *

Address:

Country

Address Line 1

City

State/Province

Postal Code

Phone: (Required)

Years Known: (Required)

Description:

Military Record in the U.S. Armed Forces

Branch of Service:

Date of Entry:

Date of Discharge:

Service Schools, Special Training or Assignments:

Have you ever been excluded from participating in a Federal Healthcare Program? Any plan or program that provides health benefits whether directly, through insurance or otherwise, which is funded directly through insurance in whole or part by the United States Goverment?

If yes, give a detailed explanation:

Are you able , as far as you know, to perform all of the essential functions of the job(s) you are applying for, with or without reasonable accommodations?

If no, please list required accommodation(s):

Additional Documentation

Upload Resume or Additional Documentation (optional):

No file selected

Click or drag here to add files

Upload Additional Documentation (optional)

No file selected

Click or drag here to add files

Certification

By signing this application I certify that the information I have provided to the foregoing questions is true and correct to the best of my knowledge and belief, and that no attempt has been made to conceal information. Furthermore, I authorize my former and present employers, schools, and personal references to provide any information they have regarding me, whether or not it is on their records. I hereby release them and The Lutheran Care Network to the fullest extent from all liability for divulging the requested information. I understand that if any information given by me in this application and/or the attached resume is found to be false or misleading, I will be subject to dismissal at anytime during the period of my employment.

If employment is obtained under this application, I will comply with all rules, regulations, policies, and procedures of The Lutheran Care Network (TLCN). I agree to be responsible for all property and equipment issued to me by TLCN until it is returned by me. I agree to submit to any/all physical examination(s) by TLCN and understand that my employment is contingent upon a satisfactory medical clearance, and Chauncey, Office of Inspector General (OIG), National Practitioner Data Bank (NPDB), Office of the Professions (OP), and/or any other applicable accrediting agency's databank search. Further, I understand and agree that unless my position is covered by a collective bargaining agreement or other written employment agreement that my employment is at will and for no definite period of time, and may be terminated at any time with or without cause or prior notice by TLCN or myself. I further understand that this at will employment relationship may not be changed by any written document or by conduct unless

By signing this application I certify that the information I have provided to the foregoing questions is true and correct to the best of my knowledge and belief, and that no attempt has been made to conceal information. Furthermore, I authorize my former and present employers, schools and personal references to provide any information they may have regarding me, whether or not it is on their records. I hereby release them and The Lutheran Care Network to the fullest extent from all liability for divulging the requested information. I understand that if any information given by

me in this application and/or the attached resume is found to be false or misleading, I will be subject to dismissal at anytime during the period of my employment.

Signature of Applicant (Required)

Date

Month

Day

Year

Coburg Village Employment Application

Personal Information

Education

Foreign Languages

Licenses and/or Certifications

Employment History

Professional References

Military Record in the U.S. Armed Forces

Additional Documentation

Certification

Coburg Village is a part of The Lutheran Care Network a ministry of healing, hospitality and community through partnerships in caring. The Lutheran Care Network is committed to the physical, emotional and spiritual needs of seniors.