PossAbilities of Southern Minnesota

1808 Third Avenue Southeast

Rochester MN 55904

EMPLOYMENT APPLICATION

PossAbilities is an Equal Opportunity/Affirmative Action Employer

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            We consider applicants for all positions without regard to race, color, creed, religion, national origin, sex, disability, age, marital status, sexual orientation, or status with regard to public assistance.

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POSITION APPLYING FOR: _________________________________________________

Previous Employment with PossAbilities of Southern MN:             YES [  ]           NO [  ]

Date you would be available to begin work________________________________________

Are you 18 years of age or older    [   ] Yes                  [   ] No

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Applicant Name: __________________________      S.S. # ______________________________

Address: _______________________________________________________________________

City, State: _______________________________            Zip Code: _______________________

Home Phone: (____) ____ - ________                   

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EMPLOYMENT EXPERIENCE: Start with your present or last job or attach a resume.  Include any job-related volunteer activities.  If you need more space, use back of page.

Employer: ______________________________________________________________________

Job Title:  _______________________________Wage: _________Hours per Week:_________

Work Performed: ________________________________________________________________

Employed from _______ to ______             Reason for leaving __________________________

 Employer: ___________________________________________________________________

Job Title:  _____________________________ Wage: __________Hours per Week:_________

Work Performed: ________________________________________________________________

Employed from _____ to _____                  Reason for leaving __________________________

 Employer: _____________________________________________________________________

Job Title:  __________________________      Wage: ___________Hours per Week:________

Work Performed: ________________________________________________________________

Employed from ____ to ____                  Reason for leaving ____________________________

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PLEASE LIST YOUR EDUCATION & TRAINING (indicate highest level first) (Proof of Degree required upon employment)

_________________________________________________________________________________________

School                                                           Course of Study                                   Degree earned

_________________________________________________________________________________________

School                                                           Course of Study                                   Degree earned

_________________________________________________________________________________________

School                                                           Course of Study                                   Degree earned

DESCRIBE ANY ADDITIONAL SKILLS OR SPECIALIZED TRAINING: ___________________________________________________________________________________________________________________

_________________________________________________________________________________________

A HIGH SCHOOL DIPLOMA OR GED?                                             [   ] YES     [   ] NO

A CURRENT DRIVER’S LICENSE?                                                      [   ] YES     [   ] NO

A CURRENT  FIRST AID CERTIFICATION?                                      [   ] YES     [   ] NO

A CURRENT CPR CERTIFICATION?                                                  [   ] YES     [   ] NO

LIST ANY OTHER QUALIFICATIONS/CERTIFICATES OR LICENSES HELD: _______________________________________________________________________________________

HAVE YOU BEEN CONVICTED OF A FELONY WITHIN LAST 7 YEARS    [   ] YES     [   ] NO

(If “yes” specify (Conviction will not necessarily disqualify an applicant from employment)):

_________________________________________________________________________________________

HAVE YOU EVER BEEN INVOLVED IN A SITUATION FOR SUBSTANTIATED ABUSE OR NEGLECT OF A VULNERABLE ADULT/CHILD?                                                                    [   ] YES     [   ] NO

If “yes”, specify ____________________________________________________________________________

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            PossAbilities will make reasonable accommodations which will enable qualified applicants to be considered for any position, perform essential functions of the job or enjoy benefits of employment.

ARE YOU PREVENTED IN ANYWAY FROM BEING IN ATTENDANCE MOST DAYS OF THE YEAR?

                                                [   ] YES                 [   ] NO

 PLEASE LIST PROFESSIONAL OR WORK-RELATED REFERENCES (Name/address/phone)

1. ______________________________________________________________________________

________________________________________________________________________________

2. ______________________________________________________________________________

________________________________________________________________________________

3. ______________________________________________________________________________

________________________________________________________________________________

MAY WE CONTACT THE ABOVE LISTED REFERENCES                      [  ] YES  [  ] NO

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             I certify answers given herein are true and complete to the best of my knowledge.

             I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

             This application will be kept on file for a period of one year, however, a new application must completed for each new position applied for.

              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 the 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.

             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 by all rules and regulations of the employer.

______________________________________________                ___/___/___

Signature of Applicant                                                                      Date

THE AGENCY’S ACCEPTANCE OF THIS APPLICATION DOES NOT CONSTITUTE AN OFFER OF EMPLOYMENT.