Apply for an Employment Opportunity Fill out the application below and we'll be in touch! "*" indicates required fields Step 1 of 5 20% Personal InformationName* First Middle Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work PhoneCell NumberBest Time To Contact YouEmail Address* Social Security Number (Voluntary):If a driver’s license is needed to perform the essential duties of the position, are you able to provide an active, valid, applicable driver’s license?* Yes No (If yes, verification will be required.)Are you legally eligible for employment in this country?* Yes No (If yes, verification will be required.)Are you 18 years of age or older?* Yes No Equal Employment Opportunity InformationWoodland Centers considers all applicants without regard to race, color, creed, religion, national origin, sex, disability, age, marital status, status with regard to public assistance or sexual orientation or any other legally protected status. The information requested below will be used to evaluate our efforts to reach all segments of the population and in reviewing our selection and placement efforts, the information is VOLUNTARY and PRIVATE. It is detached and retained separately from your work history. It is not referred to Unit Directors or Supervisors. If we request additional information related to your disability, it will be maintained as SEPARATE and PRIVATE medical records. We appreciate your cooperation in our efforts to ensure Affirmative Action and Equal Employment Opportunity. Any false statement may be punishable by law.Please Check the Appropriate Box for Gender:* Male Female Identify as below Identify As:With Which Racial/Ethnic Group Do you Identify? Please check all that apply:* American Indian or Alaska native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. Black or African American: A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Other Disability Status, Defined as: a physical or mental impairment that substantially limits one or more of the major life activities, has a record or such impairment is regarded as having such an impairment. Do you claim Disability Status:* Yes No Position applying for:*Date available to work?*What is your minimum salary requirement?*Were you referred by someone? If so, please list their name:Employment Conditions: Check as many as you are willing to work.* Regular, full-time Regular, part-time Temporary, full-time Temporary, part-time EducationCollege*Name and Address of InstitutionCourse of Study Major/MinorCircle Last Year CompletedDid you Graduate?Diploma / Degree Add RemoveOther (Specify)Name and Address of InstitutionCourse of Study Major/MinorCircle Last Year CompletedDid you Graduate?Diploma / Degree Add RemoveOther (Specify)Name and Address of InstitutionCourse of Study Major/MinorCircle Last Year CompletedDid you Graduate?Diploma / Degree Add RemoveWork Related Licensure (Check appropriate)* LICSW LP MD RN LMFT LPN LADC LPN LPCC NONE Licensed Professionals: Have you ever been reprimanded, censured, or otherwise disciplined by, or have you been subject to a corrective action/plan by an licencing board, peer review organization, third party payer, clinic, hospital, medial staff, or any health-related agency or organization? Yes No If yes, explain: Employment ExperienceList present and past employers beginning with your most recent positionDate Employed From/To*Employer*Job Title*Employer Phone Number*Employer Address*May we contact this employer?*YesNoIf no, please explain:* Full-Time Part-Time Other Summarize the nature of work performed and job responsibilities:*Reason for Leaving*Employer 2Date Employed From/To*Employer*Job Title*Employer Phone Number*Employer Address*May we contact this employer?*YesNoIf no, please explain:* Full-Time Part-Time Other Summarize the nature of work performed and job responsibilities:*Reason for Leaving*Employer 3Date Employed From/ToEmployerJob TitleEmployer Phone NumberEmployer AddressMay we contact this employer?YesNoIf no, please explain: Full-Time Part-Time Other Summarize the nature of work performed and job responsibilities:Reason for Leaving ReferencesList people who know you well, preferably from a work environment. Do not refer to an acquaintance or relative.*NameRelationship/TitleCellphone or email address Add RemoveReferences #2*NameRelationship/TitleCellphone or email address Add RemoveReferences #3NameRelationship/TitleCellphone or email address Add Remove Signature of ApplicantThis application will be considered active during the time period recruitment takes place for the specified position for which it was submitted or a period not to exceed 30 days. Any applicant wishing to be considered for employment beyond this time should inquire as to whether or not applications are being accepted at that time. I understand that any employment relationship with Woodland Centers is of an "at-will" nature, which means that Woodland Centers retains the right to terminate its employees at any time for any reason not prohibited by law; that an employee has the right to resign employment at any time for any reason (subject to Woodland Centers notice request defined within the Human Resources Policy Manual) and that these mutual rights constitute Woodland Centers' at-will policy. I 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 the Chief Executive Officer of Woodland Centers or their designee. I understand further that the Human Resources Policy manual does not constitute an employment contract and may be changed or eliminated at Woodland Centers discretion. I understand that if the position I am applying for is within a program licensed by the State of Minnesota, I will be subject to a background investigation upon employment and that my continued employment is subject to the outcome of this investigation. If the position applied for (or any subsequent future position) involves driving, I authorize Woodland Centers to check my driving record (MVR) now, and at future intervals as may be deemed appropriate by Woodland Centers, and understand that a record of motor vehicle violations, including alcohol related offenses, may make me ineligible for consideration or continued employment in a driving related position. I certify that the answers given in this application for employment are true and complete. I authorize the investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I specifically authorize Woodland Centers to make an investigation of my past employment and educational background. I hereby release all persons, past and present employers, and educational institutions from any liability to me if they supply information to Woodland Centers as a part of this investigation. Your SignatureDate* MM slash DD slash YYYY
