Employment Application Employment Application SEMCIL IS AN AFFIRMATIVE ACTION - EQUAL OPPORTUNITY EMPLOYER. WE EMPLOY INDIVIDUALS WITHOUT REGARD TO RACE, COLOR, AGE, SEX, RELIGION, MARITAL STATUS, NATIONAL ORIGIN, SEXUAL ORIENTATION, DISABILITY OR ANY OTHER LEGALLY PROTECTED STATUS Please complete the employment application in its entirety. Click the section header to access information contained in each section. Personal Information Last Name * First Name * Middle Name * Street Address * County City * State * Zip * Home Phone * Cell Phone * Are you at least 18 years of age? * Yes No Are you legally eligible to work in the United States? * Yes No Federal Law requires proof of identity and employment authorization for all new employees. Email * Position Applying For Job Title * Location * Hours Desired * Full Time Part Time Earnings Expected Per Year Month Year Earnings Expect are per Hours and days which you are available to work Sunday Monday Tuesday Wednesday Thursday Friday Saturday Available Start Date * Can you travel if the job requires it? * Yes No Do you have a valid driver's license? * Yes No Who referred you to SEMCIL? If newspaper, please give name of newspaper Education / Training Please input all the schools you attended by selecting the "add" button to add additional schools School * High School College Graduate School Business or Trade School Other Name * Location * Diploma, Degree and Major * Graduated? * Yes No Add Remove Military History Are you a Veteran? * Yes No Duties Performed Tranining Received and Work Experience Employment History Please input three employers by selecting the "add" button. List your present or most recent employer first. Name of Company Type of Business Address City State Zip Position / Title Brief Description of Job Supervisor's Name Title Phone Number Dates of Employment From To Starting Salary Per Year Month hour Ending Salary Per Year Month Hour Reason for leaving May we contact this employer? Yes No Add Remove Professional References Please input three professional references by selecting the "add" button to add additional references. Reference Name * Not former supervisor or relative Occupation Email * Phone Number * Number of Years Known * Add Remove Technology Skills List All Skills and Software Applications You Have Experience Using Word processing Spreadsheet Other Software Database Microsoft Office * Yes No Power Point * Yes No Scanner * Yes No Copier * Yes No Digital Phone Systems * Yes No Explain Internet Skills, Including Email Usage Professional Licenses or Certificates Held Additional Information Have you ever been a defendant in a professional malpractice litigation? * Yes No **Driving on company time is an ever-present possibility as part of your potential employment. As a result, an acceptable motor vehicle record (MVR) review may be required** Consent to obtain information for employment purposes 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. Applicant's Signature * Date * Notice to Applicants 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. Volunteer Affirmative Action Questions 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 Applicant Name Date Position Applied For Section 2: Referral Source Online Ad Newspaper Referred by Current Employee Reffered by Current Client Employment Agency Other Section 3: Applicant Affirmative Action Data - Please complete A - Gender Male Female Do not wish to identify 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. Hispanic or Latino Yes A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. NOT Hispanic or Latino Caucasian Yes A person having origins in any of the original peoples of Europe, the Middle East, or North Africa Black or African American Yes A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander Yes A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Asian Yes A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. American Indian or Alaska Native Yes A person having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. Two or more races (Not Hispanic or Latino) Yes All persons who identify with more than one of the above five races. Do not wish to identify Yes All persons not wishing to self-identify race/ethnicity Upload Optional Resume and/or Cover Letter File Upload Drop a file here or click to upload Choose File Maximum upload size: 5MB If you are human, leave this field blank.