Application Form

* = required field

* Today′s Date (MM/DD/YY) * Last Name * First Name * Middle Name Position Applying For

* Present Address * City, State * Zip Code * Primary Phone (include area code) Other Phone (include area code) * E-mail

* Are you currently employed? Yes No * May we contact your employer? N/A Yes No * Seeking Full-time Part-time When are you available to start? Earnings Expected

* This position requires that you are at least 18 years old, can you meet that requirement? Yes
No

* If hired, can you furnish proof that you are eligible to work in the U.S.? Yes
No

If no, please explain

* Have you applied at or worked for Access before? Yes
No

If yes, when? (month/year)

What was your position?

* Have you ever been convicted of abuse? Yes
No

If yes, please explain (include date)

* Have you been convicted of a crime(s) in the last 10 years, or are you currently under the terms of a deferred adjudication or similar program? (Do not answer "Yes" if your conviction record has been annulled, expunged, sealed, pardoned, erased, or impounded.) Yes
No

If yes, please explain (include date)

* Have you ever been disciplined or discharged by an employer? Yes
No

If yes, please explain (include date)

* Referral Source (check all that apply):
Advertisement (please identify)

Employee (please identify)

Other (please identify)

Education

High School: * Name of School * Location (city, state) * Did you graduate? Yes No GED

College: Name of School Location (city, state) Did you graduate? Yes No Current Student Degree and Area of Study Number of Years Attended

Other Education: Name of School Location (city, state) Did you graduate? Yes No Current Student Degree and Area of Study Number of Years Attended

Employment Record

Start with current/most recent employment and work backward; include military experience

* Employer * Location (city, state) * Phone Number (include area code) * Dates Employed * Position Held * Duties Performed * Supervisor * Ending Pay * Reason for Leaving

Previous Employer Location (city, state) Phone Number (include area code) Dates Employed Position Held Duties Performed Supervisor Ending Pay Reason for Leaving

Previous Employer Location (city, state) Phone Number (include area code) Dates Employed Position Held Duties Performed Supervisor Ending Pay Reason for Leaving

* May we contact your previous employers? Yes
No

If no, please explain

References

NOTE: Please do not include family members.

* Name * Phone Number (include area code) * City, State * Relationship * # of Years Known

* Name: * Phone Number (include area code) * City, State * Relationship * # of Years Known

* Name * Phone Number (include area code) * City, State * Relationship * # of Years Known

Availability

NOTE: Many direct care positions require overnights and weekend hours.

* How many weekends are you available to work per month? (please select your maximum preference) One
Two
Three
Four

* How many overnights are you available to work each week? (please select your maximum preference) None
One
Two
Three
Four

* Number of Hours Seeking per Week:
Minimum: Maximum:

* Please indicate hours available: (also indicate a.m. and p.m.)

Sunday
Earliest: Latest:

Monday
Earliest: Latest:

Tuesday
Earliest: Latest:

Wednesday
Earliest: Latest:

Thursday
Earliest: Latest:

Friday
Earliest: Latest:

Saturday
Earliest: Latest:

Please provide any other relevant qualifications to the position for which you are applying:

Working with Clients

Transportation

* As a direct care staff, you will need to transport Access clients in your vehicle. Do you have an operating vehicle/car? Yes
No

* Do you have a current driver’s license? Yes
No

* Do you have current motor vehicle insurance? Yes
No

* Will you have a clear motor vehicle report (i.e. non-suspended license)? Yes
No

Background Checks

* Background checks are required. Will you have a clear background and fingerprint check? Yes
No

Services Preference

* We provide services to both adults and children. Do you have a preference? Yes
No

* If you chose yes, for what group do you have a preference? Adult
Children
Both

Client Assistance

* Some of our clients are physically disabled and require help with personal cares. Are you comfortable assisting with all bathing and toileting duties? Yes
No

Client Behavior

* Some of our clients can be verbally or physically behavioral. Are you comfortable with aggressive behaviors? Yes
No

Client/Shift Requirements

* Some sites require that staff be over age 21. Do you meet this requirement? Yes
No

* Client shifts at Access typically start after 2:30 p.m. Are you available to work with a child after school for 2 to 5-hour shifts? Yes
No

* Our 24-hour sites require an 8-hour overnight. Are you available to work a straight 18-hour shift? Yes
No

* Weekends are scheduled every other weekend. Can you work weekends? Yes
No

* Some client sites require staff to work early mornings. Can you work early mornings starting at 6:00 a.m. to 8:00 a.m.? Yes
No

Employment Duration

* What duration of employment are you seeking? Seasonal work (i.e. school year/summer)
Long range

Pre-employment Statement

1. Any offer of employment I may receive from Access of the Red River Valley is contingent upon my successful completion of the agency's pre-employment review process including the agency's receiving references that it considers satisfactory, and my satisfactory completion of any post offer pre-employment or post-employment medical exams I may be required to take disclosed to Access.
2. I understand that as a condition of employment at Access, I may be required to undergo and successfully pass a screening for alcohol and/or drugs. I also understand and agree that, if employed, I may be required to submit to an alcohol or drug screening at any time at the discretion of Access of the Red River Valley. I hereby consent to having the results of any such alcohol or drug screening I may be required to undergo disclosed to Access.
3. In processing my application for employment, the agency may verify all information provided by me, or have prepared an investigation consumer report for this purpose concerning my prior employment, military record, education, character, general reputation, personal characteristics, and criminal record. I understand that upon the written request of the company, I will be informed whether an investigation consumer report was requested and given full information as to the nature and scope of this investigation. All employees are required to pass a Minnesota State Background check. Unfavorable responses from that state shall result in the withdrawal of any employment (or employment offers) and termination.
4. In consideration of my employment, I agree to comply with the policies, rules, regulations, and procedures of the agency, and I understand that my compensation and conditions of employment can be changed by the agency at any time. I understand that any employment relationship with the agency is of an "at-will" nature, which means that the employee may resign at any time, and the employer may discharge at any time without cause. I further understand that no manager or representative of the agency, other than the Executive Director, has any authority to enter into any agreement with me for employment for any specified period of time or to make any agreement different from or contrary to the foregoing. I further understand that any such agreement, if made, shall not be enforceable unless it is in writing and signed by myself and the Executive Director.
5. By my signature, I promise that information provided in this employee application (and in any related documentation) is true and complete, and I understand that any false or misleading information or significant omissions may disqualify me from consideration for employment, and may lead to my dismissal from employment, if discovered at a later day. I agree to immediately contact Access if I should be convicted or plead guilty to any crime while my job application is pending, or during my period of employment by Access.
6. I authorize any person, school, current or prior employer named in this form (or related documentation or interview) to provide Access with any information and opinion requested by Access in connection with my application, and I release such persons, employers, and schools from any liability in making such statements.
7. I understand that this application does not create a contract of employment. I understand that, if hired, I am obliged to comply with any and all current and subsequently adopted Access policies, and that Access does not offer contracts, promises, or representations related to employment. I understand and agree that, if hired, my employment is for no definite period of time, and may, regardless of the date of payment of wages or salary, be terminated at any time and for any reason.

By entering my name in the box below, I understand that I will submit an electronic signature, stating that I have read the above "Pre-Employment Statement," I understand it fully, and I will adhere to it.

* Please Enter Name: (please type your full name)

After the application is received, we will contact you about continuing the application process. These forms and Job descriptions may be viewed in our Access office.