Employment Application

Position Applied for*

Last Name*

First Name*

Middle Initial*

Address

Street Address Address Line 2 City State ZIP Code

Home Phone*

Other Phone

Email Address*

Are you 18 years of age or older?*

Yes
No

Are you a United States Citizen or have permission to work in the U.S.?*

Yes
No

Availability Information

I am available to begin work on*

Employment Type*

I will accept full-time employment.
I will accept part-time employment.

Formal Education

[High School / GED] Name / Location

[High School / GED] Dates of Attendance (M/Y)

[High School / GED] Degree / Certificate Received

[High School / GED] Major or Emphasis

[College / University] Name / Location

[College / University] Dates of Attendance (M/Y)

[College / University] Degree/Certificate Received?

[College / University] Major or Emphasis

[Trade / Technical School] Name/Location

[Trade / Technical School] Dates of Attendance (M/Y)

[Trade / Technical School] Degree/Certificate Received?

[Trade / Technical School] Major or Emphasis

List any other applicable skills, training, or proficiencies:

Occupational License

(if applicable)

License Type

License Number

License Issue Date

License Expiration Date

Work Experience

Provide a complete description of all qualifying experience, paid and/or volunteer, starting with the most recent position held.

May we contact your present employer?*

Yes
No
Yes, only after an offer has been made.

[Employer 1] Employer Name

[Employer 1] Position Title

[Employer 1] Address

[Employer 1] Duties

[Employer 1] Supervisor Name

[Employer 1] Telephone

[Employer 1] Start Date (m/y)

[Employer 1] End Date (m/y)

[Employer 1] Reason for Leaving

[Employer 2] Employer Name

[Employer 2] Position Title

[Employer 2] Address

[Employer 2] Duties

[Employer 2] Supervisor Name

[Employer 2] Telephone

[Employer 2] Reason for Leaving

Applicant Information

Gender*

Race / Ethnic Group*

CAUCASIAN - (Not of Hispanic origin), includes persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
BLACK OR AFRICAN AMERICAN - All persons having origins in any of the Black African racial groups; not of Hispanic origin.
HISPANIC OR LATINO - Persons of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race.
AMERICAN INDIAN OR ALASKAN NATIVE - All persons having origins in any of the original peoples of North America.
ASIAN OR PACIFIC ISLANDER - All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands.
MULTIPLE RACES - or 2 or more races:

Multiple Races / Ethnic Groups*

Disability Status

A person with a disability is defined as:

Having a physical or mental impairment which substantially limits one or more major life activities.*
Having a record of such an impairment.
Being regarded as having such an impairment.

*Major life activities include caring for oneself, performing manual tasks, walking,talking, hearing, seeing, speaking, breathing, learning, and working.

Note: Temporary, non-chronic impairments, with little or no long-term impact, are usually not disabilities. A visual problem which has been corrected by glasses is usually not a disability. Veterans who are rated as “disabled” by the Veterans Administration are not automatically “disabled” under this definition.

Based on the above information, do you claim disability status?*

Yes
No

Do you have special needs which may necessitate accommodations in the hiring process?*

If hired, job accommodations will be considered based on your individual needs in performing the essential job functions of the vacant position

Yes
No

Please describe the type of accommodation needed:*

Policies & Signature

Non-Discrimination

Recovery Alliance Duluth is an equal opportunity and veteran-friendly employer. All qualified applicants will receive consideration for employment without regard to race, creed, gender, age, color, national origin, religion, disability, sexual orientation, marital status, or status with regard to public assistance.

Data Privacy*

I have read the data privacy notice.

Minnesota Statutes Chapter 13 requires that you be informed of the following about private data requested on this application.

Name, home address and telephone numbers, and email address are used to identify you and to contact you about potential job opportunities. If your name is not provided, we won’t be able to process your application. If your contact information is not provided, we will not be able to contact you and may reject your application.
Gender, Race/Ethnic group, and Disability Status are used to comply with equal employment opportunity and affirmative action requirements and to evaluate our efforts to ensure legal diversity in the recruitment and selection of employees. If this data is not provided, it will be more difficult for us to evaluate our efforts and to provide accurate data in the required reports.

Reasonable accommodation information is used to provide reasonable accommodations in hiring processes. If
sufficient data is not provided, we may not be able to accommodate you.

Conviction information is used to determine if we may legally accept an application from you and to determine whether a conviction is job-related. If you don’t provide it, we may not be able to determine if we can legally hire you.

You are not legally required to provide any of the private data listed above. Recovery Alliance Duluth management/ supervisory employees involved in the selection process may have access to your private data if their work assignments reasonably require access. Others who may legally access the above data are individuals or agencies to whom we are required to release the data by law, rule, or court order.

ATTENTION - THIS STATEMENT MUST BE SIGNED. ANY FALSE STATEMENT ON THIS APPLICATION IS PUNISHABLE BY LAW.*

I agree to this statement.

I authorize Recovery Alliance Duluth and any agent acting on its behalf to conduct an inquiry into any job-related information contained in this application. I hereby authorize all current and previous employers (unless noted otherwise on this form) to release any information in their files pertaining to my employment history.

I certify that all of the statements in this application are true, complete, and correct to the best of my knowledge and belief and are made in good faith. I understand that any false information or omission of information from this application may be cause for rejection or dismissal if employed. I have read the Data Privacy Notice (page 4) and agree to supply the information on this form with full knowledge of that warning.

Signature

Today's Date*