Application for Employment

Please Note:
Completing this application online form is a quick way to start the application process for a direct care position at Access. Once we receive your online application, we will contact you about continuing the process (for example, there are additional forms and questionnairres to complete, such as a MN Background Study form). If you are applying for a professional positon, the position you are applying for requires other items such as letters of reference or a cover letter, these will need to be mailed or brought in to the Access office in a timely manner as closing dates may apply..

Items in RED are required in order for the form to be submitted online.

Access of the Red River Valley is an equal employment opportunity employer and will not discriminate against any applicant or employee on any grounds protected under federal, state, or local law, including race, color, creed religion, age, sex, sexual harassment, national origin, ancestry, marital status, handicap, disability related to pregnancy or childbirth, affectional or sexual preference, membership or activity in any local commission, or status regarding public assistance, membership, or non-membership in any labor organization, or any other characteristic protected under federal, state, or local law. None of the questions in this application are intended to elicit information regarding any protected characteristics, nor imply any limitations, preference, or discrimination based protected characteristics.

If you are hired by Access of the Red River Valley, you will be employed on an at-will basis. As an at-will employee, you may terminate your employment at any time and for any reason. Similarly, if you are hired, Access of the Red River Valley will have the right to terminate your employment at any time and for any reason.

Please complete this application in its entirety. Your opportunity for employment with Access will depend upon the completeness and accuracy of information on this form.

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?
Yes No N/A

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 felony in the last seven years?
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: (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: (many direct care positions require overnights and weekend hours)

How many weekends are you available to work per month? (please select your maximum preference)
None 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:

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; additional forms and questionnaires must be completed by the applicant (one example is the MN Background study form). These forms and Job descriptions may be viewed in our Access office.