Application for the Nursing Assistant Certification Class

Step 1 of 4 – Personal and Job Information

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This application is to be considered for the Nurse Aide Training Class at St. Augustine. It is not a job application, nor does it guarantee employment after successful completion of the class.

Drug Screen & Background Check Acknowledgement(Required)

By checking this box, you acknowledge that in order to BE ACCEPTED into the STNA class, you will have to take and pass a drug screen and background check.

Date Submitted

Month

Day

Year

Date Available

Month

Day

Year

Personal Information

Last Name(Required)

First(Required)

Middle

Permanent (or mailing) Address(Required)

Street Address City State ZIP Code

Are you currently living at this address?(Required)

Yes

For instance, you may be away at college or currently deployed in the Armed Forces

Present Address

Street Address City State ZIP Code

Personal Phone Number(Required)

(###)###-####

Social Security Number(Required)

Prior Names

For checking prior records, provide other names under which you are known.

Are you legally authorized to work in the United States?(Required)

Yes

Are you a United States citizen?(Required)

Yes

Have you lived in the State of Ohio for the past 5 years?(Required)

Yes

Are you age 18 or older?(Required)

Yes

Have you ever been convicted of a crime?(Required)

Yes

If yes, please give details.(Required)

General Job Information

Referred by

School

Job Fair

Current Staff Member

Other

Make your choice from this list and indicate the source in the field below

Referral detail

Which school, advertisement, job fair, or current staff member gave you this referral?

Have you ever applied for the STNA Class before?

Yes

When?

Have you ever been employed with St. Augustine/Holy Family before?

Yes

When?

Relevant Experience

Most Recent Employer

Name of Employer #1

Type of Business

Address

Street Address City State ZIP Code

Position

Salary

Dates Employed

From

Reason for Leaving

Name of Supervisor

Brief Description of Duties

Employer #2

Name of Employer #2

Type of Business

Address

Street Address City State ZIP Code

Position

Salary

Dates Employed

From

Reason for Leaving

Name of Supervisor

Brief Description of Duties

Employer #3

Name of Employer #3

Type of Business

Address

Street Address City State ZIP Code

Position

Salary

Dates Employed

From

Reason for Leaving

Name of Supervisor

Brief Description of Duties

Personal References

Please do not list family members

First Reference

Name

Phone

Relationship

Second Reference

Name

Phone

Relationship

Third Reference

Name

Phone

Relationship

Education

Are you currently attending school?

Yes

Attending

Full-time

Part-time

What courses are you taking?

Levels of Education

High School

College

Graduate School

Post-graduate

Other

Select all that apply

High School

Did you graduate?

Yes

Dates

From

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

College

Major Course of Study

Degree

Did you Graduate?

Yes

Dates

From

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Graduate School

Major Course of Study

Degree

Did you Graduate?

Yes

Dates

From

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Post-graduate School

Major Course of Study

Degree

Did you Graduate?

Yes

Dates

From

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other (Technical School, etc.)

Major Course of Study

Degree or Certificate

Did you complete your studies?

Yes

Dates

From

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Enter Email Confirm Email

Applicant’s Statement

I 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.

Acknowledgement of Applicant's Statement(Required)

I have read, understand, and agree to the above.

Untitled

First Choice

Second Choice

Third Choice

Untitled

First Choice

Second Choice

Third Choice

Application for the Nursing Assistant Certification Class

Personal Information

General Job Information

Relevant Experience

Most Recent Employer

Employer #2

Employer #3

Personal References

First Reference

Second Reference

Third Reference

Education

Applicant’s Statement

Health Campus

Holy Family

St Augustine