This application form is required by Title 63 O.S. § 1-1950.4 of state law and by the Oklahoma State Board of Health Rules OAC 310-2-15-3. This uniform application shall be used as the only application for employment of nurse aides in nursing and specialized nursing facilities, residential care homes, assisted living centers, continuum of care facilities, hospice programs, adult day care centers and home care agencies. This employer does not discriminate in its hiring decisions or in any other employment decision on the basis of race, color, sex, religion, citizenship, national origin, veteran status, age or upon a physical or mental disability which is unrelated to the applicant's/employee's ability to perform the essential functions of the position.

Personal Information

Social Security Number (Last 4)

List any other name(s) you have previously worked under, such as maiden name:

Emergency Contact Address

Employment Desired

Position Applied For

US Military Record

Prior Work History

List your last four (4) jobs beginning with your most recent or current employer

List all other employers from the past 5 years

If yes, provide reason

Educational Background

List all educational schools attended with degrees, diplomas or certificates received.

List all technical special skills or education honors, certificates, licenses, memberships or Medication Administration Technician (MAT) certification not previously listed·

If yes, where and when did you obtain.

List name, address and telephone number of three (3) references who are not relatives or former employers.

Background Information

lf you answer YES to any of the questions below, explain in the space after the question. The explanation for a YES answer should include, but not be limited to: l. State and/or jurisdiction. 2. Nature of complaint/offense. 3. Disposition of complaint and/or offense (e.g., "dismissed insufficient evidence", "deferred sentence"). 4. Date of disposition. 5. Attach copy of any correspondence received by you, the applicant, regarding the complaint/offense.

If yes, please explain.

Applicant's Certification and Agreement

lf you answer 'No' to any of the questions below, explain in the space after the question.

If no, please explain.

Previous CNA Training

Complete this section only if you will require training.

Please complete the followlng If you have had CNA Tralnlng In the past for any of these categories: LTC, HH, ADC, RC, or DDDC.

Please include Category, Program Name, Start Date, End Date

Important Information for the Job Applicant

It is unlawful for any person to provide false information regarding a criminal conviction on this uniform employment application for nurse aides. Providing false information regarding a criminal conviction is a misdemeanor under Title 63 of the Oklahoma Statutes, Section l-1950.4a. Providing false information about a criminal conviction on this application is punishable by a fine not to exceed Five Hundred Dollars ($500.00), by imprisonment in the county jail for a term of not more than one ( 1) year, or by both such fine and imprisonment.

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