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Online Application
Application for Employment
Positions without regard to race, color, religion, sex, national origin, age or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.
Step 1 of 4
25%
Date of Application
*
MM
DD
YYYY
Position(s) Applied For:
*
Which Office Location Are You Applying For? (Please check ONLY 1 office)
*
Willmar
Benson
Litchfield
Little Falls
Redwood Falls
If you are open to working in other offices, please check all that apply:
Willmar
Benson
Litchfield
Little Falls
Redwood Falls
How did you hear about us?
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Friend
Walk-in
Employment Agency
Relative
Other
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip Code
Phone
*
Email
Social Security Number
*
Date of Birth
*
MM
DD
YYYY
If you are under 18 years of age, can you provide proof of your eligibility to work?
*
Yes
No
Does Not Apply
Have you ever filed an application with us before?
*
Yes
No
If yes, give date:
MM
DD
YYYY
Are you currently employed?
*
Yes
No
May we contact your present employer?
*
Yes
No
Are you prevented from lawfully becoming employed in this country because of Visa of Immigration status?
*
Yes
No
(Proof of citizenship or immigration status will be required upon employment)
On what date could you be available for work?
*
MM
DD
YYYY
Are you currently on a lay off status or subject to recall?
*
Yes
No
Can you travel if your job requires it?
*
Yes
No
Have you been convicted of a felony within the last 7 years? (A conviction will not necessarily disqualify applicant from employment)
*
Yes
No
If yes, please explain:
Education
*
Elementary
High School
College/University
Graduate School
Diploma/Degree
CNA Certification
*
Yes
No
HHA Certification
*
Yes
No
Describe any specialized training, skills and extra-curricular activities
Describe any honors you have received
State any additional information you feel may be helpful to us in considering you as an applicant for a position
Indicate any foreign languages you can speak, read and/or write
Fluent
Good
Fair
Example: If you can speak and read Spanish fluently, you would enter - "Spanish, speak and read" - under Fluent.
List professional, trade, business or civic activities and office held
(You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, handicap or other protected status)
References (List THREE)
*
Name
Address
Phone Number
Give name, address and phone number of THREE references who are not related to you and are not previous employers.
Have you ever had any job related training in the United States military?
*
Yes
No
If yes, please describe
Are you physically or otherwise unable to perform the duties of the job which you are applying?
*
Yes
No
Employment Experience (Most Recent)
Employer
Address
Phone Number
Dates employed
From:
To:
Job Title
Salary
Starting:
Ending:
Supervisor
Reason for leaving
Work performed
_________________________________________________
Employer
Address
Phone Number
Dates employed
From:
To:
Job Title
Salary
Starting:
Ending:
Supervisor
Reason for leaving
Work performed
_________________________________________________
Employer
Address
Phone Number
Dates employed
From:
To:
Job Title
Salary
Starting:
Ending:
Supervisor
Reason for leaving
Work performed
_________________________________________________
Special Skills and Qualification
Summarize special job related skills and qualifications from other employment experience.
Applicants Statement:
*
Signature of Applicant
Date
I certify that 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 for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. 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 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.
Employment Data Record (Just Read)
Employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap or any other legally protected status. As an employer with an Affirmative Action Program, we comply with government regulations, including Affirmative Action responsibilities where they apply. The purpose for this Data Record is to comply with government record keeping, reporting and other legal requirements. Periodic reports are made to the government on the following information. The completion of this Date Record is optional. If you choose to volunteer the requested information please note that all Data Records are kept in a Confidential File and are not a part of your Application for Employment or personnel file. Please note: YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF DATA WILL NOT AFFECT ANY EMPLOYMENT DECISION.
VOLUNTARY SURVEY
Date
Government agencies at times require periodic reports on the sex, ethnicity, handicap, veteran and other protected status of employees. This data is for statistical analysis with respect to the success of the Affirmative Action program. SUBMISSION OF THIS INFORMATION IS VOLUNTARY.
Name
First
Last
Birth date
MM
DD
YYYY
Social Security #
Address
Street Address
City
State / Province / Region
Zip / Postal Code
Current Job
Check One
Male
Female
White
Black
Hispanic
American Indian/Alaskan Native
Asian/Pacific Islander
Vietnam Era Veteran
Disabled Veteran
Handicapped Individual
Please provide a copy of your:
Driver's License
Social Security Card
Please bring in your Driver's License and Social Security Card to a Divine Home Care office. Your background check cannot be completed without these.
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