I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that should an investigation disclose untruthful or misleading answers, my application may be rejected, my name removed from consideration, or my empoyment may be terminated.

I hereby give permission to Southeastern Minnesota Center for Independent Living, Inc. (SEMCIL) to make whatever inquiries it deems necessary to process my application for employment.

I understand that this application and initial interview will not guarantee that I will be hired by SEMCIL. I further understand that my employment may be determined in whole in part based on the reports issued by such agencies. I hereby release the above -mentioned parties from all liability for any damage that may result from any information obtained.

I understand and agree that, if hired, my employment is for no definite period and either Employer or I may terminate our relationship at any time, and that this employment application does not constitute an employment contract.

Applications will be considered for one year. If an applicant has not heard from the company within this time, the applicant needs to reapply to be considered further.

Southeastern Minnesota Center for Independent Living (SEMCIL) and Choice Home Care are Equal Opportunity Employers. We consider applicants for all positions without regard to race, color, religion, creed, sex, sexual orientation, national origin, ancestry, age, disability, veteran status or any other legally protected status. Applicants are invited to participate in our Affirmative Action Program by completing Section 3. In extending this invitation, you are advised that: 1) you are under no obligation to provide this information, but may do so in the future if you choose; 2) any responses you provide will remain confidential within the Human Resources Department; and 3) responses will be used only for the necessary reporting required by law.

Any information provided on this form is considered confidential information that will not be used in any hiring decision. If you decline to provide the information requested in Section 3, it will have no bearing on your application; will have no impact in our consideration of you for employment; and will not subject you to any adverse treatment. Completion of Section 3 of this form is strictly voluntary. If you choose not to provide status information, please indicate this in each of the boxes in Sections 3 A-B. If you choose to participate by completing Section 3 of this form, we thank you for your cooperation.

Section 1: General Applicant Information

B - Race/National Origin – Check the box below that corresponds to the category that best identifies your race/ethnicity.

Important:If you check the “Two or more races” box, please also check ALL boxes that identify your race/ethnicity. For example: If you identify yourself as Asian and Black, you would check 3 boxes –one for Black, one for Asian and one for two or more races.