Mountain States Health Alliance

First Name: *

Last Name: *

Email Address: *

Street Address: *

City: *

State: *

Zip: *

Daytime Phone Number: *

Secondary Phone Number: *

Are you a US Citizen?

Yes
No

Are you a Permanent US Resident?

Yes
No

State of CNA Application: *

Class dates you are interested in *

How did you hear about the course?

Have you ever been discharged from a job?

Yes
No

If yes, please explain:

Have you ever been employed by MSHA?

Yes
No

Emergency Contact Person: *

Emergency Contact Phone Number: *

Education

High School: *

City & State: *

Year Graduated: *

Undergraduate:

City & State:

Year Graduated:

Major / Degree:

Graduate:

City & State

Year Graduated:

Major / Degree:

Criminal Record

Have you been convicted of a crime?

Yes
No

If yes, please explain:

Employment

Current or most recent employer: *

Supervisor:

Employment Dates:

Duties:

Second most recent employer:

Supervisor:

Employment Dates:

Duties

Third most recent employer:

Supervisor:

Employment Dates:

Duties

Character References

Reference 1: *

Occupation: *

Phone Number: *

Years Known: *

Reference 2: *

Occupation: *

Phone Number: *

Years Known: *

Reference 3 *

Occupation: *

Phone Number: *

Years known: *

Consent Agreement

I certify that the forgoing representations are true adn correct to the best of my knowledge. I voluntarily release from liability and/or damages all parties who may issue or receive information regarding my character, previous employment, or scholastic record that may concern my application for consideration by Mountain States Health Alliance involving their Certified Nursing Assistant class.
It is my understanding that Mountain States Health Alliance will make a thorough investigation of my work and personal history and my verify all data given in my application for their Certified Nursing Assistant Class, related papers, or oral interviews. I authorize such investigation and the giving and receiving of any information requested by Mountain States Health Alliance and I release from liability any person giving or receiving such information. I understand that falsification of data given or other derogatory information discovered as a result of this investigation may prevent my being accepted into the class.
If accepted, I will accept and abide by all rules and regulations governing the class. These rules do not constitute a contract of employment and I do not construe them as much.
If requested by the management at any time, I agree to submit to search of my person and I hereby waive all claims for damanges on account of such examination.
I am responsible for necessary transportation to and from class and clinical areas.
I understand that nothing contained in this application or in the granting of an interview is intended to create an employment contract between Mountain States Health Alliance and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon Mountain States Health Alliance.
I understand that if accepted into this class, policies and rules that are issued are not conditions of employment and that the facility may review policies or procedures, in whole or in part, at any time.
A copy of this authorization may be accepted with the same authority as the original.

I have read the Consent Agreement:

Yes
No

Checking Yes serves as your digital signature

Today's Date: *