Application for Employment

It is this employer’s policy to make reasonable accommodations for persons with disabilities in the hiring process. If your disability prevents you from reading or filling out this application form, please let us know, and we will provide assistance. Title of Specific Position for Which You Are Applying Date of Application Date Available for Work Last Name First Name Middle Initial

Mailing Address City State Zip

Email Address Residence Phone

County of Residence

Are you 18 years of age or over?

9 Yes 9 No If No, Date of Birth Business Phone

Education

Did you graduate from high school or receive a GED? 9 No 9 Yes School Attended # of Years (7-20)

Name and Location of College, University, Technical Schools Did you Graduate? Certificate or Degree Course of Study 9 Yes 9 No

9 Yes 9 No

9 Yes 9 No

9 Yes 9 No

Employment

(List employment history, but do not provide dates of employment for jobs held more than five years ago.) Employing Firm

From

Month Year

To

Month Year

Address

Phone Number Supervisor

Reason for Leaving

Your Title Supervisor's Title May we contact this employer? 9 Yes 9 No If No, explain.

Principal Responsibilities

Employing Firm

From

Month Year

To

Month Year

Address

Phone Number Supervisor

Reason for Leaving

Your Title Supervisor's Title May we contact this employer? 9 Yes 9 No If No, explain.

Principal Responsibilities

Employing Firm

From

Month Year

To

Month Year

Address

Phone Number Supervisor

Reason for Leaving

Your Title Supervisor's Title May we contact this employer? 9 Yes 9 No If No, explain.

Principal Responsibilities

Are you willing to work overtime?

Yes No

What shift would you prefer? (If applicable)

1st 2nd 3rd

Are you willing to work other shifts? No Yes

If Yes, what shifts? 1st 2nd 3rd

Job Relevant Volunteer and Unpaid Work Experience

Kind of Volunteer Activity (Do not specify organization.) Major Responsibilities # Hours/Week Length of Service Describe any additional experience or training that qualifies you for this job References

(Give us the names of three people outside of relatives who can be contacted regarding your qualifications, work habits and character.) Name Present Address Phone Position and relation to your work Military

Did you serve in the military service of this country and separate under honorable conditions from any branch of the armed forces of the U.S. after having served on active duty for 181 consecutive days or by reason of disability incurred while serving on active duty? 9 Yes 9 No Felony Conviction

Have you served a sentence in jail or prison or been convicted of a felony for which a jail sentence could have been imposed? You may answer "No" is the conviction or criminal records have been annulled, sealed, set aside or purged or if you have been pardoned pursuant to the law. 9 No 9 Yes If "Yes," attach a separate sheet with explanation. Information concerning this question will not be used to automatically bar your from employment but may be used to direct your interests to areas less related to the areas of your conviction.

In connection with this application for employment, I authorize the employer and any agent acting on it’s behalf to conduct an inquiry into any job-related information contained in this application, including, but not limited to, my records maintained by an educational institution relating to academic performance such as transcripts. Moreover, I hereby release the employer and any agent acting on it’s behalf from any and all liability of whatsoever nature by reason of requesting such information from any person. 9 Yes 9 Yes, but not present employer until job is offered. 9 No (We may be unable to hire you without this information.) I declare that any statement in this application or information provided is true and complete and hereby acknowledge that I have read and understand the information above. Date Signature (Do not print)

IMPORTANT FACTS ABOUT INFORMATION ON YOUR APPLICATION This application is to assist in the hiring process. Certain information requested on the application is not public. It will be released only to you or to persons within the organization who need to know it in order to perform their job duties. If you are employed, the data will be available to the Internal Revenue Service and the Social Security Administration for payroll and tax purposes. Private Data Why we ask for it Are you legally obligated to provide it? What may happen if you don't provide it? Date of Birth (If under 18)

Mailing Address

Residence Telephone

Sex, Racial/Ethnic Group,

Disability status (This information

is requested on a separate form.)

Felony Conviction

To comply with child labor laws.

To be able to send you notices.

To be able to contact you to determine availability for interview.

To be able to make Equal Opportunity reports as

required by law.

To determine whether we may legally accept an

application from you and to determine whether

your record may be a job-related consideration.

Yes

Yes

No

No

Yes

Failure to provide information may be cause for

rejecting an application.

Failure to provide information may be cause for

rejecting an application.

We might not be able to contact you for an

interview.

We will not be able to determine whether our

selection process results in unfair discrimination, or to take affirmative action in our hiring.

We will not be able to make determinations

required by law.

In accordance with the Immigration Reform and Control Act of 1986, this employer hires only U.S. Citizens and lawfully authorized alien workers. If hired, you will be required to provide written documentation of citizenship or legalized alien program. Failure to provide said documentation will result in dismissal.

Minn. Stat. Sec. 518.611, Subd. 8, requires employers to obtain information from all new employees regarding court-ordered child support obligations that are required by law to be withheld from income. Failure to provide said documentation will result in dismissal. If you are hired for this position you may be required to undergo a physical examination and/or drug screening and/or background check at this employer’s expense to determine whether or not you are able to perform the duties of this position in an effective and safe manner, and whether or not accommodations need to be made for you. This employer has the right to verify information provided in the application. False information may be grounds for rejecting this application or for dismissal following employment.

This employer is an EQUAL OPPORTUNITY EMPLOYER/CONTRACTOR and encourages applications from women, minorities and disabled persons. This employer does not discriminate against or harass any employee or applicant for employment because of race, color, creed, religion, national origin, sex, sexual orientation, disability, age, marital status, or status with regard to public assistance. This employer does not discriminate on the basis of disability status in the admission or access to, or treatment of employment in its programs or activities. It is the policy of this employer to provide reasonable accommodations to the known physical and mental limitations of qualified disability applicants and employees in order for them to perform the essential functions of the job in question. It is intended that this application be placed in the public domain, not subject to copyright protection. The application may be duplicated or altered without permission. The Minnesota Department of Employment and Economic Development shall not be liable for the use of this application, in any form, or the use of the information provided in the application.

May 2004

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