APPLICATION FOR EMPLOYMENT

Personal

Full TimePart TimeTemporary

YesNo

YesNo

Early Mornings/DaysEveningsSleep OvernightsWeekendsOther

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Employee Referral

Other

YesNo

YesNo

Education

None123456789101112

N/AYesNo

01234567

Business References

List people from your previous employment, other than relatives, familiar with your work performance.

Employment History

Please account for all periods of employment. Start with the most recent, describe ALL paid, military and applicable voluntary experience. Highlight your knowledge; skills and abilities, which best demonstrate your qualifications for this position. You may list significantly different jobs within the same organization as separate items. A resume may be attached to supplement information. Information requested below must be completed.

Full TimePart Time

Full TimePart Time

Full TimePart Time

YesNo

YesNo

Special Activities & Contacts

Military Service Record

YesNo

Other Information

YesNo

Certification

  1. I authorize this organization to make any investigation deemed necessary for employment considerations, promotion or transfer within the organization. I understand that this includes, but is not limited to criminal background check and motor vehicle driving records. I authorize all persons, schools, employers and law enforcement authorities to release any information concerning my background, including all information contained in this application and information provided in the interview. I hereby release any said persons, school, employers and law enforcement authorities from all liability in responding to inquiries in connection with my application for employment.
  2. Any acceptance of employment will be predicted upon the truthfulness of the written and verbal statements contained within this application and the pre-employment process. I understand that should my employer find that any statement I have made is not truthful, any offer of employment will be withdrawn and if employed, may be subject to dismissal.
  3. If selected for employment, I will comply with the safety, work and attendance policies of my employer.
  4. I understand that any offer of employment is contingent upon presentation on my start date of acceptable proof of identity and right to work in the United States.
  5. I understand this employment application is not to be construed as a guarantee of employment for a specific time. I understand that if I am selected, my employment with this organization will not constitute any form of contract, implied or expressed and such employment is “at will” which means that either I or ICAN, Inc. may terminate the employment relationship at any time and for any or no reason. If hired, my at will” employment status may only be changed by a written employment agreement signed by an authorized representative. No Ican, Inc supervisor has the authority to offer or promise anything other than “at-will” employment.

By my signature, I acknowledge having read and understand the above statement and I promise that the information provided in this employment application (and accompanying resume or documentation, if any) is true and compete. I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part to any employment at ICAN, Inc. I understand that all information on this application is subject to verification and I consent to references, former employers and education institutions listed being contacted regarding this application. I further authorize ICAN, Inc. to rely upon and use, as it sees fit, any information received from such contacts. I agree to immediately notify Ican if I should be convicted of a felony or any crime while my job application is pending, or during my period of employment, if hired. I also understand that I have the right to receive a copy of this acknowledgment should I request a copy.

Affirmative Action / Equal Employment Opportunity

ICAN Inc. of Waseca is an equal opportunity employer. We monitor and report all employment activity to ensure that our equal employment opportunity and affirmative action policies are being enforced. This information will be kept secure and separate from personnel files. Providing information regarding race, sex, and disability status will not affect any employment decisions.

Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment.

Please answer the following:

I choose not to complete this section.American Indian or Alaska NativeAsianAfrican AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderWhiteTwo or More Races

I choose not to complete this section.YesNo

I choose not to complete this section.MaleFemale