6739 Golden Valley Rd
Golden Valley, Minnesota 55427
Hugh.Aylward@kellynorton.org

Oasis Program: 763-544-1447
Bill Kelly House: 612-726-1502

Application for Employment

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, diability, marital or veteran status, or any other legally protected status.

GENERAL INFORMATION

Position(s) Applying For:

Date of Application:

Which facility are you applying for? (Check all that apply)

Bill Kelly House

Oasis Program

How did you learn about us?

Full Name

Address

Phone Number

Email Address

Best time to contact you at home is:

AMPM

Have you ever filed an application with us before? If Yes, give date:

Yes No

Have you ever been employed with us before? If Yes, give date:

Yes No

Do any of your friends or relatives work here?

Yes No

Are you currently employed?

Yes No

May we contact your present employer?

Yes No

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment

Yes No

Date available for work:

What is your desired salary range?

Are you available to work:

Full-Time

Day Evening Overnight

Part-Time

Day Evening Overnight

Temporary

Are you currently on "lay-off" status and subject to recall?

Yes No

Can you drive the work van if needed?

Yes No

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

EDUCATION

High School

Undergraduate College

Graduate / Professional

Other (Specify)

Specialized Training

Military Job Training

EMPLOYMENT EXPERIENCE
Please start with your present or last job

1. Employer Information

Dates Employed

Hourly Rate/Salary

Work Performed

2. Employer Information

Dates Employed

Hourly Rate/Salary

Work Performed

3. Employer Information

Dates Employed

Hourly Rate/Salary

Work Performed

4. Employer Information

Dates Employed

Hourly Rate/Salary

Work Performed

Special Job Related Skills and Qualifications

Experience Serving Clients with Mental Illness

Additional Information

Are you capable of performing in a reasonable manner, with or without reasonable accommodation, the activities involved in the job or occupation for which you have applied? A review of the activities involved in such a job or occupation has been given.

Yes No

REFERENCES

Reference 1

Reference 2

Reference 3

APPLICANT'S STATEMENT

I certify that answers given herein are true and complete.

I authorize investigation of all statements contained in this application for employement as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicatble law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of the organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Date: