EMP-FORM-TEST – St. Cloud HRA

Equal Opportunity Statement

We are an Equal Opportunity Employer. All applicants are considered for all positions without regard to race, religion, color, sex, gender, sexual orientation, pregnancy, age, national origin, ancestry, physical/mental disability, medical condition, military/veteran status, genetic information, marital status, ethnicity, citizenship or immigration status, or any other protected classification, in accordance with applicable federal, state, and local laws. By completing this application, you are seeking to join a team of hardworking professionals dedicated to consistently delivering outstanding service to our customers and contributing to the financial success of the organization, its clients, and its employees. Equal access to programs, services, and employment is available to all qualified persons. Those applicants requiring an accommodation to complete the application and/or interview process should contact a management representative.

Position(s) Applied For

Date of Application

Full Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Main Phone Number

Alternate Phone Number

Email Address

Employment Experience

List your three most recent employers, starting with the most recent. Account for all periods of time including military service and any periods of unemployment. If self-employed, provide firm name and business references.

Employer 1 (Most Recent)

Employer Name

Supervisor Name

May We Contact This Employer?

Yes
No

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Employer Phone Number

Date Employed — From

Date Employed — To

Job Title and Duties

Reason for Leaving

Employer 2

Employer Name (2)

Supervisor Name (2)

May We Contact This Employer? (2)

Yes
No

Employer Address (2)

Address Line 1

Address Line 2

City

State

Zip Code

Employer Phone Number (2)

Date Employed — From (2)

Date Employed — To (2)

Job Title and Duties (2)

Reason for Leaving (2)

Employer 3

Employer Name (3)

Supervisor Name (3)

May We Contact This Employer? (3)

Yes
No

Employer Address (3)

Address Line 1

Address Line 2

City

State

Zip Code

Employer Phone Number (3)

Date Employed — From (3)

Date Employed — To (3)

Job Title and Duties (3)

Reason for Leaving (3)

Additional Employment Questions

Have you ever been involuntarily terminated or asked to resign?

Yes
No

Explain any gaps in your employment history

Other experience, skills, languages, or qualifications you feel are relevant

Education

Describe your educational background below.

High School

School Name — High School

Diploma/Degree Received? — High School

Yes
No

Area of Study / Major — High School

Specialized Training, Skills, or Extracurricular Activities — High School

College / University

School Name — College / University

Diploma/Degree Received? — College / University

Yes
No

Area of Study / Major — College / University

Specialized Training, Skills, or Extracurricular Activities — College / University

Graduate / Professional School

School Name — Graduate / Professional School

Diploma/Degree Received? — Graduate / Professional School

Yes
No

Area of Study / Major — Graduate / Professional School

Specialized Training, Skills, or Extracurricular Activities — Graduate / Professional School

Trade School

School Name — Trade School

Diploma/Degree Received? — Trade School

Yes
No

Area of Study / Major — Trade School

Specialized Training, Skills, or Extracurricular Activities — Trade School

Other Education

School Name — Other Education

Diploma/Degree Received? — Other Education

Yes
No

Area of Study / Major — Other Education

Specialized Training, Skills, or Extracurricular Activities — Other Education

Business and Professional References

List three professional references of individuals who are not related to you.

Professional Reference 1

Name and Title (Professional Ref 1)

Relationship (Professional Ref 1)

Phone Number or Email (Professional Ref 1)

Professional Reference 2

Name and Title (Professional Ref 2)

Relationship (Professional Ref 2)

Phone Number or Email (Professional Ref 2)

Professional Reference 3

Name and Title (Professional Ref 3)

Relationship (Professional Ref 3)

Phone Number or Email (Professional Ref 3)

Personal References

List three people who know you well.

Personal Reference 1

Name and Title (Personal Ref 1)

Relationship and Years Acquainted (Personal Ref 1)

Phone Number or Email (Personal Ref 1)

Personal Reference 2

Name and Title (Personal Ref 2)

Relationship and Years Acquainted (Personal Ref 2)

Phone Number or Email (Personal Ref 2)

Personal Reference 3

Name and Title (Personal Ref 3)

Relationship and Years Acquainted (Personal Ref 3)

Phone Number or Email (Personal Ref 3)

General Information

Have you ever used another name?

Yes
No

Is any additional information relative to name changes, use of an assumed name, or nickname necessary to enable a check on your work and educational record?

Yes
No

Have you ever worked for this company before?

Yes
No

Do you have friends and/or relatives working for this company?

Yes
No

On what date are you available to begin work?

Hours Available — Monday

Hours Available — Tuesday

Hours Available — Wednesday

Hours Available — Thursday

Hours Available — Friday

Hours Available — Saturday

Hours Available — Sunday

Are you available to work?

Full time
Part time
Shift work
Temporary

If hired, do you have a reliable means of transportation to and from work?

Yes
No

Can you travel if the position requires it?

Yes
No

Can you relocate if the position requires it?

Yes
No

Are you at least 18 years old?

Yes
No

Age Note

Note: If under 18, hire is subject to verification that you are of minimum legal age.

If hired, can you present evidence of your identity and legal right to work in this country?

Yes
No

Are you able to perform the essential job functions of the job for which you are applying with or without reasonable accommodation?

Yes
No

ADA Note

Note: We comply with the Americans with Disabilities Act and consider reasonable accommodation measures that may be necessary for qualified applicants/employees to perform essential job functions.

Applicant Statement and Agreement

Read and initial each paragraph below. Ask if there is anything that you do not understand.

Statement 1 — Authorization to Investigate

I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the prior employers and references I have listed to disclose to the company any and all letters, reports, and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers, and all other persons, corporations, partnerships, and associations from any and all claims, demands, or liabilities arising out of or in any way related to such investigation or disclosure.

Initials — Statement 1

Statement 2 — Compliance with Rules

In the event of my employment with the company, I understand that I am required to comply with all rules and regulations of the company.

Initials — Statement 2

Statement 3 — At-Will Employment

If hired, I understand and agree that my employment with the company is at will and that neither I nor the company is required to continue the employment relationship for any specific term. I further understand that the company or I may terminate the employment relationship at any time, with or without cause, and with or without notice. I understand that the at-will status of my employment cannot be amended, modified, or altered in any way by any oral modifications.

Initials — Statement 3

Statement 4 — Safety Commitment

I understand that the safety of employees is extremely important to the company and that the company is committed to ensuring a safe working environment. I understand that I, and every employee, have a responsibility to prevent accidents and injuries by observing all safety procedures and guidelines and following the directions of my site supervisor. I understand and agree to comply with federal, state, and local regulations related to on-the-job safety and health.

Initials — Statement 4

Statement 5 — Certification of Truth

I hereby certify that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

Initials — Statement 5

Statement 6 — I-9 Requirement

I understand that if I am selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration law requires me to complete an I-9 Form in this regard.

Initials — Statement 6

Severability

I understand that if any term, provision, or portion of this Agreement is declared void or unenforceable, it shall be severed, and the remainder of this Agreement shall be enforceable.

Agreement Attestation

My signature attests to the fact that I have read, understand, and agree to all of the above terms.

Name (Print)

Date Signed