Employment Application
Employment experience
(If yes, verification will be required.)
Personal information
(Some jobs may require a Class A, B, C or D license)
Education
Skills
To be completed by applicants for labor and skilled trade positions
Signature of applicant
It is understood and agreed upon that any misrepresentation by me on this application will be sufficient cause for cancellation of this application and/or separation from the employer's service if I have been employed. I give the employer the right to investigate all references and to secure additional information about me, if job-related. I hereby release from liability the employer and its representatives from seeking such information and all other persons, corporations or organizations for furnishing such information. The employer is an Equal Opportunity Employer. The employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state or federal law. This application is current for 3 months. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application. I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the employer has the authority to make any assurances to the contrary. I understand it is this county's policy not to refuse to hire a qualified individual with a disability because of this person's need for an accommodation that would be required by the ADA.
NOTICE TO APPLICANTS FOR EMPLOYMENT (Tennessen Warning)
Minnesota law requires that you be informed of the purposes and intended uses of the information you provide to the Olivia Hospital and Clinic during the application process or during employment. Any information about yourself that you provide to the Olivia Hospital and Clinic during the application process will be used to identify you as an applicant and to assess your qualifications for employment with Olivia Hospital and Clinic. If you wish to be considered for employment, you are required to provide the information requested in the Application for Employment. If you refuse to supply information requested by Olivia Hospital and Clinic, it may mean that your application will not be considered. You are hereby advised that, under Minnesota Law, the following information about you must be made available to any member of the public who requests it: Veterans Relevant Test Scores Rank on Eligible Lists Job History Education and Training Work Availability Your name will not be made available to the public unless you are selected to be interviewed by Olivia Hospital and Clinic. If you are selected to be interviewed by Olivia Hospital and Clinic, your name will also be made available to any member of the public who requests it. Other information about yourself that you provide during the application process or during employment with Olivia Hospital and Clinic is classified as private under state law, except as listed as public here or as listed in Minn. Stat. 13.01.Et seq.. That is, the information may not be provided to members of the public except: 1. persons authorized to have access to the information under state or federal law; and 2. persons authorized by court order to have access to the information; and 3. persons to whom you consent in writing to have access to information. All individuals in the county who need to know information will have access. The applicant (signature below) has read and understands the information contained in this document.
List present and past employers beginning with your most recent position
References
Names of any relative working for Olivia Hospital & Clinic
Name: *
Name: *
Address
Address
Are you legally eligible for employment in this country? *
Are you legally eligible for employment in this country? *
Are you fluent in a language (including sign language) other than English? *
Are you fluent in a language (including sign language) other than English? *
Are you 18 years of age or older? *
Are you 18 years of age or older? *
Position applying for: *
Position applying for: *
Employment conditions: check as many as you are willing to work. *
Employment conditions: check as many as you are willing to work. *
Do you have a valid Class D (regular) driver's license? *
Do you have a valid Class D (regular) driver's license? *
License number
License number
High school *
High school *
College *
College *
Other (specify)
Other (specify)
Other (specify)
Other (specify)
Licenses or certificates
Licenses or certificates
List any correspondence courses, special courses, seminars, workshops, training and skills acquired that might relate to this position: *
List computer hardware and software training and experience: *
Apprenticeship(s) served or trades learned:
Apprenticeship(s) served or trades learned:
Capable of operating the following equipment:
Capable of operating the following equipment:
May we contact this employer? *
May we contact this employer? *
If no, please explain:
Wage for this position: *
Wage for this position: *
Summarize the nature of work performed and job responsibilities: *
Reason for leaving *
Employer 1
Employer 1
Employer 2
Employer 2
May we contact this employer? *
May we contact this employer? *
If no, please explain:
Wage for this position: *
Wage for this position: *
Summarize the nature of work performed and job responsibilities: *
Reason for leaving *
Employer 3
Employer 3
May we contact this employer?
May we contact this employer?
If no, please explain:
Summarize the nature of work performed and job responsibilities:
Reason for leaving
List people who know you well, preferably from a work environment. Do not refer to an acquaintance or relative. *
List people who know you well, preferably from a work environment. Do not refer to an acquaintance or relative. *
References #2 *
References #2 *
References #3
References #3
Relative #1
Relative #1
Relative #2
Relative #2
Relative #3
Relative #3
Your signature *
Your signature *