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Application for Employment
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, gender identity, disability, or any other legally protected classes.
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Indicates required field
Position applied for:
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Choose one of the following:
Employment Specialist/Job Coach
How did you hear about this position/program?
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Choose one of the following:
Indeed
Craigslist
Minnesota Job Bank
Handshake (UMD, UWS, St. Scholastica)
Northforce
Flyer/Poster
Job Fair
Company Website
Employee Referral
Other
Personal Information
First Name
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Middle Initial
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Last Name
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Phone Number
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Email
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Do you have a valid driver's license and reliable vehicle?
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Yes
No
Address
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Line 1
Line 2
City
State
Zip Code
Country
Availability (check all that apply)
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Full Time
Part Time
Days
Weekends
Nights
Available date for work:
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Have you ever been employed with us before?
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Yes
No
Have you ever submitted an application with us before?
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Yes
No
If you were employed with us before, please provide dates.
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If you submitted an application with us before, please provide dates.
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Are you able to perform the job you are applying for?
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Yes
Yes, with accommodations (see below)
Please describe any prior training and/or experience you have had working with people who have disabilities:
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Please list any accommodations you may require:
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Employment History
Provide your employment history below, listing Employer 1 as your most recent employer.
Employer 1
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Dates of Employment 1
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Job Title 1
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Address 1
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number 1
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Direct Supervisor 1
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Work Performed 1
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Reason for Leaving 1
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May we contact this employer for a reference? 1
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Yes
No
Employer 2
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Dates of Employment 2
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Job Title 2
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Address 2
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number 2
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Direct Supervisor 2
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Work Performed 2
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Reason for Leaving 2
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May we contact this employer for a reference? 2
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Yes
No
Employer 3
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Dates of Employment 3
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Job Title 3
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Address 3
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number 3
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Direct Supervisor 3
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Work Performed 3
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Reason for Leaving 3
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May we contact this employer for a reference? 3
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Yes
No
Education
College
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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Number of Years Attended
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Did you graduate?
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Yes
No
Degree / Certificate / Diploma Received (or in process)
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Vocational, Business, or Trade School
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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Number of Years Attended
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Did you graduate?
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Yes
No
Degree / Certificate / Diploma Received (or in process)
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High School / GED Program
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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Number of Years Attended
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Did you graduate?
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Yes
No
Degree / Certificate / Diploma Received (or in process)
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References
Reference 1
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Address 1
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number 1
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Reference 2
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Address 2
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number 2
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Reference 3
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Address 3
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number 3
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Employment Eligibility
Are you legally eligible for employment in the USA? (Proof of citizenship or immigration status shall be required upon employment.)
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Yes
No
Are you over 18 years of age?
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Yes
No
Voluntary Survey
Government agencies 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.
Ethnic Origin
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Choose one:
American Indian/Alaskan Native
Asian
Black
Hispanic
Native Hawaiian or Other Pacific Islander
Two or more races
White
Veteran Status
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Choose one:
Vietnam Era Veteran
Veteran with Disability
Gender
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Choose one:
Female
Male
Disability Status
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Choose one:
Individual with Disability
Applicant Verification of Truthfulness/Employment-at-will Disclosure
Before submitting your application, please review below.
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I certify that I have read the Verification of Truthfulness/Employment-at-will Disclosure statement (follow the link below) and agree fully to its terms.
Submit Application
Verification of Truthfulness/Employment-at-will Disclosure
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