Personal information

Position(s) Applied For Date of Application Last Name First Name, Middle Initial  ,  Address Home Phone Number Cell Phone Number

When are you available?

I am available to work: Full Time Part Time   I am available to work: Days Nights Weekends I am available to work: 4-hour shifts 10-hour shifts Overnight shifts Live-in shifts What days and times are you not available to work? When are you available to begin work?

What are your assets?

Do you possess: Current Drivers License Vehicle Auto Insurance with minimum WA state requirements What area can you work in? Seattle Shoreline West Seattle Bellevue Mercer Island Kirkland What skills, training, and licenses do you possess? (check all that apply) Nurse Delegate CNA - Certified Nursing Assistant NAC - Nursing Assistant Certified NAR - Nursing Assistant Registered Other:

Have you applied before?

Have you applied for work at Club 24 or Columbia Lutheran Home before? Yes No When did you apply? Were you hired? Yes No

Thank you for completing this Application of Interest for Club 24 Senior Living at Home®. Now that you’ve finished, please click on the submit button and your form will be forwarded to our office. This Application notes only your interest in employment with Club 24. A Full Application and Background Authorization form are available in our administrative office and must be completed prior to hiring.