APPLICATION FOR EMPLOYMENT Personal Position Applying (required) Full TimePart TimeTemporary First Name (required) Middle Name (required) Last Name (required) Telephone No. (required) Alt Telephone No. E-mail (required) Present Address (required) City (required) State (required) Zip (required) Are you legally eligible for employment in the USA? (if yes, verification required)YesNo Are you of legal age to work?YesNo What shifts can you work? (ICAN requires Direct Care Staff be scheduled every other weekend)Early Mornings/DaysEveningsSleep OvernightsWeekendsOther If Other Minimum Wage/Salary Desired How were you referred?Advertisement Name of Publication Employee Referral Name of Employee Other Please Specify Are you able to meet the attendance requirements of this position?YesNo Have you submitted an application with us before?YesNo If yes, when? Education Highest grade completedNone123456789101112 If you did not complete high school, do you have a high school equivalency diploma?N/AYesNo Number of years of post high school education01234567 Name and Location of College Attended Degree Major or Specialty Name and Location of College #2 Attended Degree Major or Specialty If you expect to complete an educational program in the near future, please indicate the type of degree/program and expected completion date List subjects of special study, research or training List honor societies and academic recognition Business References List people from your previous employment, other than relatives, familiar with your work performance. 1. Relationship Name Address Phone No. 2. Relationship Name Address Phone No. 3. Relationship Name Address Phone No. 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. Employer #1 (required) Phone No. (required) Address (required) City (required) State (required) Zip (required) Dates Employed (required) from to Salary Job Title (required) Job Responsibilities (required) Full TimePart Time Reason for Leaving (required) Employer #2 Phone No. Address City State Zip Dates Employed from to Salary Job Title Job Responsibilities Full TimePart Time Reason for Leaving Employer #3 Phone No. Address City State Zip Dates Employed from to Salary Job Title Job Responsibilities Full TimePart Time Reason for Leaving Are you currently employed?YesNo May we contact your current and previous employers?YesNo Special Activities & Contacts List and describe any conferences, workshops, seminars, training programs or professional organizations in which you have participated. These could be supervisory, extension courses, non-degree university programs, etc. taken on company time or on your own time. Describe the major content of the course or organization and your purpose for attending. List any other information you would like us to consider Military Service Record Were you in U.S. Armed Forces?YesNo If yes, what Branch? Other Information Are you willing to provide your own transportation if necessary for your employment?YesNo Certification 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. 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. If selected for employment, I will comply with the safety, work and attendance policies of my employer. 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. 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. Applicant Signature (required - type your full name) 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: RaceI choose not to complete this section.American Indian or Alaska NativeAsianAfrican AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderWhiteTwo or More Races Do you have a disability?I choose not to complete this section.YesNo SexI choose not to complete this section.MaleFemale Δ
