CNA Training Application

Personal Information

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Daytime Phone*

Evening Phone*

Email

Employment Information

Are you 18 years of age or older?*

Yes
No

Do you have a High School Diploma or GED?*

Yes
No

Have you previously enrolled or completed a C.N.A. class?*

Yes
No

What year were you previously enrolled in or did you complete a C.N.A. class?

Have you previously been employed by the Indiana Masonic Home of Compass Park?*

Yes
No

Please list dates and positions in which you were employed by the Indiana Masonic Home of Compass Park

Are you legally authorized to work in the United States?*

Yes
No

How did you hear about Indiana Masonic Home at Compass Park C.N.A. Training?*

Walk-in
Newspaper
Friend
School
Other

You answered 'Other' to the previous question, please explain.

What shift are looking to work upon completion of the class?*

Days
Evenings
Nights
Weekends

Education and Training

High School

Name of High School*

High School City & State*

City State

High School Major/Degree*

Years Completed*

Graduated*

Yes
No

Name of College/University*

College/University

College/University City & State*

City State

College/University Major/Degree*

Years Completed*

Graduated*

Yes
No

Trade /Business School

Name of Trade /Business School*

Trade/Business School City & State*

City State

Trade/Business School Major/Degree*

Years Completed*

Graduated*

Yes
No

Criminal History

Have you ever been convicted of or pled guilty to a felony or misdemeanor other that a minor traffic-related infraction?*

Yes
No

If yes, state nature of the conviction or plea, the date, the court and the jurisdiction*

Do you have any pending charges for a felony or misdemeanor other than a minor traffic-related infraction?*

Yes
No

If yes, state nature of the pending charges, the date, the court and the jurisdiction.*

Reference Information

List three (3) personal references (non-family members).

Name - Reference #1*

First Last

Relationship - Reference #1*

Phone - Reference #1*

Name - Reference #2*

First Last

Relationship - Reference #2*

Phone - Reference #2*

Name - Reference #3*

First Last

Relationship - Reference #3*

Phone - Reference #3*

Employment History

Starting with your present or most recent job, list all your employment experience, including part-time or temporary employment for the past 5 years.

Employer:

Employer Address

Street Address City State

Job Title

Immediate Supervisor

Employment Dates:

From

To

Starting Salary/Hourly Rate:

Final Salary/Hourly Rate:

Work Performed:

Reason for Leaving:

Discharged
Voluntary Resignation
Involuntary Resignation

Add another position to the Employment History Section?*

Yes
No

Position 2

Employer:

Employer Address

Street Address City State

Job Title

Immediate Supervisor

Employment Dates:

From

To

Starting Salary/Hourly Rate:

Final Salary/Hourly Rate:

Work Performed:

Reason for Leaving:

Discharged
Voluntary Resignation
Involuntary Resignation

Add another position to the Employment History Section?*

Yes
No

Position 3

Employer:

Employer Address

Street Address City State

Job Title

Immediate Supervisor

Employment Dates:

From

To

Starting Salary/Hourly Rate:

Final Salary/Hourly Rate:

Work Performed:

Reason for Leaving:

Discharged
Voluntary Resignation
Involuntary Resignation

Add another position to the Employment History Section?*

Yes
No

Position 4

Employer:

Employer Address

Street Address City State

Job Title

Immediate Supervisor

Employment Dates:

From

To

Starting Salary/Hourly Rate:

Final Salary/Hourly Rate:

Work Performed:

Reason for Leaving:

Discharged
Voluntary Resignation
Involuntary Resignation

Add another position to the Employment History Section?*

Yes
No

Position 5

Employer:

Employer Address

Street Address City State

Job Title

Immediate Supervisor

Employment Dates:

From

To

Starting Salary/Hourly Rate:

Final Salary/Hourly Rate:

Work Performed:

Reason for Leaving:

Discharged
Voluntary Resignation
Involuntary Resignation

Additional Employment History Information

May we contact the employers listed above?*

Yes
No

If no, indicate which one(s) you do NOT wish us to contact and provide the reason why you prefer that we not contact the employer(s).*

Have you ever been discharged, permitted to resign rather than be discharged, or asked to resign from any position?*

Yes
No

If yes, please state the employer and the reason for the discharge or resignation.*

Consent and Agreements

I completed this C.N.A. Training Class Enrollment Form and confirm all information in it is true and complete to the best of my knowledge. I understand that false, misleading or omitted information may result in the rejection of my enrollment and the revocation of being accepted into the training class.*

First Last

I hereby consent to a release of information from law enforcement agencies, the criminal justice system, be it federal, state or local to the Indiana Masonic Home at Compass Park of any prior criminal history, arrest record or Child Protection Service History.*

First Last

I authorize the Indiana Masonic Home at Compass Park to contact my references, current and past employers and release all parties from liability for damage(s) that may result from furnishing information concerning my current and/or present employment and any pertinent information they may have, personal or otherwise.*

First Last

Date*

Name

This field is for validation purposes and should be left unchanged.