Application for Employment

Please complete the application form as thoroughly as possible. Do not mark your application “see resume.” Resumes may be included, but will not be accepted in lieu of a completed application form. The information provided in the form will be used to assess your qualifications for the position. Applications and supporting documents must be received by the deadline date on the job posting.

Applicant Information

Position Applied For*

Full Name*

First Middle Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Best time to call

: HH

MM

Cell

Best time to call

: HH

MM

Email Address*

Referral Source

Have you been employed by us before?*

Yes
No

If Yes, When?

Have you ever filed an application with us before?*

Yes
No

If Yes, When?

Date available for work*

Type of employment desired*

Full-Time
Part-Time
Temporary

Are you currently employed?*

Yes
No

Are you on lay‐off and subject to recall?*

Yes
No

Will you travel if job requires it?*

Yes
No

Do you possess a valid Minnesota Drivers License?*

Yes
No

If you are under 18, are you eligible to work?*

Yes
No

Are you legally eligible for employment in this country?*

Yes
No

(Proof of Citizenship or immigration status will be required upon employment)

Employment Section

List your last four (4) employers, assignments or volunteer activities, starting with the most recent, including military experience. Explain any gaps in employment in comments section below. You may exclude organizations which indicate race, color, creed, religion, national origin, sex, age, disability, sexual orientation, marital status or other protected status.

Employer

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Immediate Supervisor and Title

Job Title

Starting Hourly Rate/Salary

Final Hourly Rate/Salary

Summarize the nature of the work performed and job responsibilities

Dates Employed From

To

Reason for Leaving

May we contact for reference?

Yes
No
Later

Employer

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Immediate Supervisor and Title

Job Title

Starting Hourly Rate/Salary

Final Hourly Rate/Salary

Summarize the nature of the work performed and job responsibilities

Dates Employed From

To

Reason for Leaving

May we contact for reference?

Yes
No
Later

Employer

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Immediate Supervisor and Title

Job Title

Starting Hourly Rate/Salary

Final Hourly Rate/Salary

Summarize the nature of the work performed and job responsibilities

Dates Employed From

To

Reason for Leaving

May we contact for reference?

Yes
No
Later

Employer

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Immediate Supervisor and Title

Job Title

Starting Hourly Rate/Salary

Final Hourly Rate/Salary

Summarize the nature of the work performed and job responsibilities

Dates Employed From

To

Reason for Leaving

May we contact for reference?

Yes
No
Later

Comments

(including explanation of any gaps in employment)

Skills and Qualifications

Summarize any special training, skills, licenses, certificates and/ or characteristics of yourself that may qualify you as being able to perform job‐related functions for the position which you are applying.

Educational Background

High School Name and Location

High School Grades Completed

High School Diploma/GED

None
Diploma
GED

High School Extracurricular Activities

Describe any skills, special training, apprentice, and extracurricular activities that relate to the position for which you are applying.

High School Honors

Describe any honors you have received.

Undergraduate College/University Name and Location

Undergraduate College/University Years Completed

Undergraduate College/University Degree

Undergraduate College/University Extracurricular Activities

Describe any skills, special training, apprentice, and extracurricular activities that relate to the position for which you are applying.

Undergraduate College/University Course(s) of Study

Undergraduate College/University Honors

Describe any honors you have received.

Technical/Graduate/Professional School Name and Location

Technical/Graduate/Professional School Years Completed

Technical/Graduate/Professional School Degree

Technical/Graduate/Professional School Extracurricular Activities

Describe any skills, special training, apprentice, and extracurricular activities that relate to the position for which you are applying.

Technical/Graduate/Professional School Course(s) of Study

Technical/Graduate/Professional School Honors

Describe any honors you have received.

Professional, trade, business or civic associations

List professional, trade, business, or civic associations and any offices held. (You may exclude memberships which would reveal, sex, race, age, religion, national origin, color, disability or other.)

Special accomplishments, publications or awards

List special accomplishments, publications, awards. (You may exclude memberships which would reveal, sex, race, religion, age, national origin, color, disability or other.)

Additional Information

List any additional information you would like us to consider.

References

List name and phone number of three (3) business/work references who are NOT related to you. If not applicable, list three (3) school or personal references who are not related to you.

Name*

Phone Number*

Years Known*

Please enter a number from 0 to 120.

Name*

Phone Number*

Years Known*

Please enter a number from 0 to 120.

Name*

Phone Number*

Years Known*

Please enter a number from 0 to 120.

Disclaimer and Signature

It is understood and agreed upon that any misrepresentation by me on this application or in my interview will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed.
I give the employer the right to investigate all references and to secure additional information about me, if job‐related. I hereby release from liability the employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.
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.
This application is current for one (1) year. 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.
The employer is an Equal Opportunity Employer. The employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state or federal law.

Signature*

Applicant Information

Employment Section

Educational Background

References

Disclaimer and Signature

Affirmative Action Voluntary Information

Special Notice