Information Driver

Each question should be fully and accurately answered on this form. PLEASE PRINT NEATLY.

Incomplete or illegible aplications may not be processed. Prospective employees will receive consideration without discrimination based on race, creed, color, sex, age, national origin, handicap or veteran status. Date

Last Name First Full Middle

Mailing Address City State Zip Code

Physical Address City State Zip Code

Previous Address City State Zip Code

How long at current address? How long at previous address? e-mail address Home Phone Cell Phone Other Phone

Social Security Number Current MN driver's license? No Yes Driver's License number:

Are you 18 years of age or older? No Yes

Are you legally eligible for employment in the United States? No Yes Are You a U. S. Citizen? No Yes Are you a U.S. Veteran? No Yes The following information is voluntary and will be used to determine preference in hiring, in accordance with Leech Lake Band Member preference. Ethnic Background: Hispanic Caucasian African-American other: Native American/Alaskan Native: Leech Lake District: one two three Enrollment number: MCT (band) Enrollment number: other (Tribe/Band) Enrollment number:

Have you ever applied for employment with us before? No Yes If yes, when?

Position desired Secondary position desired

Pay Expected Pay Expected

What skills or training do you have that is related to the job for which you are applying? What machines or equpment can you operate that are related to the job for which you are applying? Availability: Full-time Part-time Seasonal Temporary Education Did you Degree

Level graduate or diploma

High yes

School no

Trade or yes

Technical no yes no yes no

College

Graduate

Education

Employment Application

Leech Lake Band Of Ojibwe - Housing Authority

Personal Information Employment

Name and location of school Course of study

Company name Company telephone number

Company Address Employed (mm/yy)

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Name of supervisor and supervisor's title Rate of pay (hourly or weekly) start end

Job title (describe your work) Reason for separation Company name Company telephone number

Company Address Employed (mm/yy)

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Name of supervisor and supervisor's title Rate of pay (hourly or weekly) start end

Job title (describe your work) Reason for separation Company name Company telephone number

Company Address Employed (mm/yy)

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Name of supervisor and supervisor's title Rate of pay (hourly or weekly) start end

Job title (describe your work) Reason for separation Company name Company telephone number

Company Address Employed (mm/yy)

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Name of supervisor and supervisor's title Rate of pay (hourly or weekly) start end

Job title (describe your work) Reason for separation Employers listed above may be contacted for reference unless you indicate those you would prefer we don't contact. Do not contact: Reason:

Did you serve in the U.S. Armed Forces? No Yes If yes, what branch? Years of service (mm/yy)

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Describe any training received in the service relevant to the position for which you are applying. Contact #1 Name Relationship Telephone Address

Contact #2 Name Relationship Telephone Address

Doctor Clinic/Hospital Name Telephone Address

Emergency medical information (allergies, medication, etc.) Are you able, either with or without reasonable accomodations, to perform the essential functions of the job for which you are applying? No Yes

Employment History Military

Give accurate and complete employment record, beginning with the most recent, moving down for the past Emergency Info

Name Relationship Name Relationship

Name Relationship Name Relationship

Name Relationship Name Relationship

The Leech Lake Housing Authority believes that all persons are entitled to equal employment opportunity and does not discriminate against applicants for employment on the basis of race, color, creed, religion, national origin, age, sex, political affiliation or physical or mental impairment, provided the applicant is qualified and meets the physical requirements for the position for which they are applying. Both equal employment opportunity and Band member preference will apply to employment opportunities. Application of these policies should not be construed to deny employment or employment benefits to current or prospective employees of the Leech Lake Housing Authority. In an effort to exercise its tribal sovereignty, the Leech Lake Housing Authority will grant Band member preference to its employees and qualified applicants, when deemed appropriate. Preference will be granted to qualified individuals in the following order:

1. Enrolled Leech Lake Band Member

2. Enrolled member of the Minnesota Chippewa Tribe 3. Enrolled federally recognized Tribal member

4. Enrolled Canadian Reserve Tribal Member

The Leech Lake Housing Authority Board of Commissioners reserves the right to appoint the most qualified candidate regardless of race, color, creed, religion, national origin, age, sex or political affiliation, while still recognizing and and following Band member preference. Advertisement: Newspaper (name paper) Internet (name website) Walk-in Current Employee (name) Posted flyer (where?) other (list) Governmental Employment agency Private Employment agency It is understood and agreed upon that any misrepresentation contained within this application will be sufficient cause of cancellation of this application and/or separation of employment if I have been employed. Furthermore, I understand that just as I am free to resign at anytime, the employer reserves the right to terminate my employ- ment at anytime, with or without cause and without prior notice. I understand that this document is not to be construed as a contract and no single represtative of the employer has the right to guarantee or deny employment. I further understand that the Leech Lake Housing Authority is an Alcohol and Drug free workplace, and upon consideration for hire, I will be subject to both pre-employment and random drug and alcohol testing. I give the employer, or prospective employer, the right to investigate all references and to secure additional information about me, if job related. I hereby release the employer, or prospective employer and its representatives from liability for seeking such information and all other persons, corporations or organizations for furnishing such information. This application is current for six months from the date received. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application. Signature date

List friends and relatives that are currently employed by the Leech Lake Housing Authority Friends and Relatives Referral Source

Contact this candidate