Creating & Having Opportunities in Community Environments

Application for Employment

An Equal Opportunity Employer
We are an Equal Opportunity Employer and fully subscribe to the principles of Equal Opportunity . We have adopted an Affirmative Action Program to ensure that all applicants and associates are considered for hire, promotion and job status without regard to race, color, religion, sex, national origin, age, or disability.

Position(s) Applied For: _____________________________________________
Date of Application: ________________________________________________
How did you hear about this position/program? __________________________

Personal Information

Last Name _____________________________________
First Name _____________________________________
Initial _____________________________________
Social Security Number ____________________________
Telephone Number(s) ________________________
Street Address __________________________________
City ___________________________________
State __________________________________
Zip ____________________________________
Date available for work ____________________

In case of emergency, notify:
Name __________________________________
Address ________________________________
Telephone ______________________________

I am interested in working: (Please check all that apply)
___ Full-time ___ Part-time ___ Weekend hours
___ AM ___ PM

Please indicate specific hours if you have restrictions: ___________________________________

How many miles are you willing to travel to location of employment? _______________________

Have you ever filed an application with us before? ___ Yes (Date ____________) ___ No
Have you ever been employed with us before? ___ Yes (Date ____________) ___ No

Are you able to perform the job you are applying for? ___ Yes ___ No
If no, what accommodations can be made? ___________________________________________

Please describe any prior training and/or experience you have had working with people who have disabilities.
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Employment History

We may contact employers listed below unless you indicate those you do not want us to contact. Do not contact:
Employer Number(s) ______________________________________
Reason ________________________________________

Please give employment information beginning with most recent position.

Employer __________________________________________________
Job title ___________________________________________________
Dates Employed ____________________________________________
Supervisor _________________________________________________
From _____________________________________________________
To _______________________________________________________
Address __________________________________________________
Reason for leaving ___________________________________________
Hourly rate/Salary ___________________________________________
Starting: __________________________________________________
Final: _____________________________________________________
City/State/Zip ______________________________________________
Work Performed ____________________________________________
Telephone(s) ______________________________________________


Employer __________________________________________________
Job title ___________________________________________________
Dates Employed ____________________________________________
Supervisor _________________________________________________
From _____________________________________________________
To _______________________________________________________
Address __________________________________________________
Reason for leaving ___________________________________________
Hourly rate/Salary ___________________________________________
Starting: __________________________________________________
Final: _____________________________________________________
City/State/Zip ______________________________________________
Work Performed ____________________________________________
Telephone(s) ______________________________________________


Employer __________________________________________________
Job title ___________________________________________________
Dates Employed ____________________________________________
Supervisor _________________________________________________
From _____________________________________________________
To _______________________________________________________
Address __________________________________________________
Reason for leaving ___________________________________________
Hourly rate/Salary ___________________________________________
Starting: __________________________________________________
Final: _____________________________________________________
City/State/Zip ______________________________________________
Work Performed ____________________________________________
Telephone(s) ______________________________________________


Employer __________________________________________________
Job title ___________________________________________________
Dates Employed ____________________________________________
Supervisor _________________________________________________
From _____________________________________________________
To _______________________________________________________
Address __________________________________________________
Reason for leaving ___________________________________________
Hourly rate/Salary ___________________________________________
Starting: __________________________________________________
Final: _____________________________________________________
City/State/Zip ______________________________________________
Work Performed ____________________________________________
Telephone(s) ______________________________________________

Employer __________________________________________________
Job title ___________________________________________________
Dates Employed ____________________________________________
Supervisor _________________________________________________
From _____________________________________________________
To _______________________________________________________
Address __________________________________________________
Reason for leaving ___________________________________________
Hourly rate/Salary ___________________________________________
Starting: __________________________________________________
Final: _____________________________________________________
City/State/Zip ______________________________________________
Work Performed ____________________________________________
Telephone(s) ______________________________________________

Education

College
Name/Address of School _____________________________________
Number of Years Attended ___________________________________
Did you Graduate? ___ Yes ___ No
Degree/Certificates Received or in Process ______________________
Degree _________________________________________________
Major ___________________________________________________
Minor ___________________________________________________
Vocational, Business or Trade School
Name/Address of School _____________________________________
Number of Years Attended ___________________________________
Did you Graduate? ___ Yes ___ No
Degree/Certificates Received or in Process ______________________
Degree _________________________________________________
Major ___________________________________________________
Minor ___________________________________________________
High School
Name/Address of School _____________________________________
Number of Years Attended ___________________________________
Did you Graduate? ___ Yes ___ No
Degree/Certificates Received or in Process ______________________
Degree _________________________________________________
Major ___________________________________________________
Minor ___________________________________________________

Personal References:

Give below the names of three additional references whom you have known at least one year (no relatives or former employers). Please note that we may contact these people for reference information.

Name & Occupation ______________________________________
Full Address ____________________________________________
Phone ________________________________________________
Relationship to You ______________________________________
Years Aquainted ________________________________________

Name & Occupation ______________________________________
Full Address ____________________________________________
Phone ________________________________________________
Relationship to You ______________________________________
Years Aquainted ________________________________________

Name & Occupation ______________________________________
Full Address ____________________________________________
Phone ________________________________________________
Relationship to You ______________________________________
Years Aquainted ________________________________________


Driving Status:

Do you have a valid Driver’s License? ___ Yes ___ No
Driver’s License # _____________________________________
State: ______________________________________________
If no, please explain: ___________________________________

For insurance purposes, we will need the following information. Please indicate below if your driving record reflects any of the following violations: (Please feel free to add explanatory comments in space below.)

________ More than two moving violations, accidents, or combination during the past three years.

________ A conviction for reckless driving, DWI, careless driving, drug related offenses, suspension or revocation of license during the past ten years.

________ A felony conviction involving the use of a motor vehicle during your lifetime.

Employment Eligibility

1. Are you 18 years of age and older? ___ Yes ___ No

2. Are you legally eligible for employment in the USA? ___ Yes ___ No
(Proof of citizenship or immigration status shall be required upon employment.)

3. Have you every been convicted of any offenses such as homicide, crimes against the person, crimes of compulsion, sex crimes, incest, theft and burglary, arson or obscene phone calls? ___ Yes ___ No

4. Further Comments: __________________________________________________________________________________________
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PLEASE READ

The Minnesota Department of Human services regulations require that employees not present a risk of transmission of reportable communicable diseases; are free of chemical abuse, and have physical and mental abilities to perform job responsibilities. We are also obligated to contact your past employers over the last 5 years in the mental health/human service field to request information concerning the occurrence of sexual contact with clients/patients.

Applicant Verification of Truthfulness/Employment-at-will Disclosure

I certify that the answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in the application for employment as may be necessary in arriving at an employment decision.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

I further understand that the employment policies and practices of this organization are subject to modification, revocation, suspension, termination, or change by the organization at any time with or without notice. Furthermore, such policies and practices contained in the employee handbook do not constitute a contract between the organization and me. I understand that the organization will apply such policies and practices to particular situations as it deems to be in the best interest of the organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide buy all rules and regulations of the employer.

Signature____________________________________________Date:____________________________________


Employment Data Record

Employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or disability, or any other legally protected status.As an employer with an Affirmative Action Program, we comply with government regulations, including Affirmative Action responsibilities where they apply.The purpose for this Data Record is to comply with government record keeping, reporting and other legal requirements. Periodic reports are made to the government on the following information. The completion of this Data Record is optional. If you choose to volunteer the requested information please note that all Data Records are kept anonymous and in a Confidential File and are not a part of your Application for Employment or personnel file. YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.

VOLUNTARY SURVEY

Date __________________

Government agencies at times require periodic reports on the sex, ethnicity, disability, veteran and other protected status of employees. The data is for statistical analysis with respect to the success of the Affirmative Action program. SUBMISSION OF THIS INFORMATION IS VOLUNTARY.

Check One: ___ Male ___ Female
Check One Of The Following : (Ethnic Origin)
___ White ___ Hispanic ___ American Indian/Alaskan Native
___ Black ___ Other ___ Asian/Pacific Islander

Check If Any Of The Following Are Applicable:
___ Vietnam Era Veteran ___ Veteran with Disability ___ Individual with Disability

Birthdate: __________________

MOTOR VEHICLE REPORT

I, _________________________________________, give CHOICE, unlimited permission to conduct an MVR (Motor Vehicle Report) of my driving record to be used in determination of hire.

The report of your driving record will be maintained by CHOICE, unlimited for two years. CHOICE, unlimited will not disclose this information to any other person, agency or organization requesting this information.

Signature: __________________________________________
Date: ______________________________________________

Please fill out the following information

1. Do you have a vehicle, valid driver’s license and verification of insurance?

2. Are you available to work weekends, evenings, late afternoons, says?
Please list when you can work.

3. Do you have any CPR/First-Aid training? If not are you willing to take the training?
Please list any training, or indicate if you will take training.

APPLICATION INFORMATION RELEASE

I hereby authorize any person, educating institution, or company I have listed as a reference below to disclose in good faith any information they may have regarding my qualifications and fitness for employment. I will hold any prior company, any former employers, educational institutions, and any other persons giving references free of liability for the exchange of this information and any other reasonable and necessary information incident to the employment process.

Applicant: Sign and date only. The reference will be chosen from your application.

Signed:_________________________________________
Date: __________________________________________

List Reference:
Comany/Organization, Educational Institution, Persons

Name: __________________________________________
Address: ________________________________________
________________________________________________
________________________________________________
Phone Number: ___________________________________

Name: __________________________________________
Address: ________________________________________
________________________________________________
________________________________________________
Phone Number: ___________________________________

Name: __________________________________________
Address: ________________________________________
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Phone Number: ___________________________________