Moorhead Employment Application

Please fill the form below as thoroughly as possible.

Full Name:	Last First M.I.
Address:	Street Address Apt/Unit #
	City State Zip
Phone:	E-mail Address:
Position Applied For:	Social Security Number: Desired Salary: $

How did you Learn about us?	When would you be available to work?
Are you currently Employed? Yes No	If yes, may we contact your employer? Yes No
Can you travel if your job requires it? Yes No	Are you currently on a layoff and subject to recall? Yes No
Are you physically or otherwise unable to perform the duties of the job for which you are applying? Yes No
Are you a citizen of the United States? Yes No	If no, are you authorized to work in the U.S.? Yes No
Have you ever worked for this company? Yes No	If Yes, When?
Have you ever been convicted of a felony? Yes No	If yes, Explain:

Education
High School:	Address:
From: To:	Did you graduate? YesNo	Degree:

College:	Address:
From: To:	Did you graduate? YesNo	Degree:

Other:	Address:
From: To:	Did you graduate? YesNo	Degree:

Languages
Indicate any foreign languages you can speak, read and/or write
Language:
	Fluent	Good	Fair
Speak
Read
Write

List professional, trade, business or civic activities and office held. (You may exclude memberships which would reveal sex, race, religion, national origin, age, ancestry, or handicap or other protected status.)
Please list three professional references.

References

Full Name		Relationship:
Company		Phone
Address		E-mail Address

Full Name		Relationship:
Company		Phone
Address		E-mail Address

Full Name		Relationship:
Company		Phone
Address		E-mail Address

Previous Employment

Company:		Phone:
Address:		Supervisor:
Job Title:
Starting Salary:		Ending Salary:
From:		To:
Responsibilities:
Reason for Leaving:

Company:		Phone:
Address:		Supervisor:
Job Title:
Starting Salary:		Ending Salary:
From:		To:
Responsibilities:
Reason for Leaving:

Company:		Phone:
Address:		Supervisor:
Job Title:
Starting Salary:		Ending Salary:
From:		To:
Responsibilities:
Reason for Leaving:

Military Service
Branch:	From:	To:
Rank at Discharge:	Type of Discharge:
If other than honorable, explain:

Driver Safety

Driver safety rules will be issued and reviewed with each driver/operator operating company vehicles, leased/rented, or personal vehicles on company business. The company endorses as company rules all applicable state motor vehicles regulations relating to driver responsibility. All accidents, regardless of severity, must be reported. No unauthorized riders, hitch-hikers, etc. are allowed in company vehicles. Under no circumstances is a company vehicle to be driven by a non-employee except in emergencies, in case of repair testing by a mechanic. Any driver who has a driver’s license revoked or suspended shall immediately notify his/her supervisor and discontinue operation of the company vehicle. (NOTE: Operating a company vehicle or personal, leased/rented on company business while under a driver’s license suspension, will result in termination of employment.) Drivers must promptly report all summonses received for moving violations during the operation of a company vehicle to their supervisor. Drivers should not operate a company vehicle for at least eight (8) hours after working fifteen (15) continuous hours. No driver shall operate a company vehicle when his/her ability to do so safely has been impaired, affected, or influenced by alcohol, drugs, medication, illness, fatigue, or injury. Each driver is responsible to ensure that his/her vehicle is in safe operating condition and is not allowed to operate the vehicle with defective steering or brakes or any other defect that would inhibit safe operation during current and foreseeable weather and light conditions. Drivers are responsible to ensure the security of company vehicles. The vehicle engine much be shut off, ignition keys removed, transmission in park, reverse or low gear, parking brake applied, and vehicle doors locked whenever the vehicle is left unattended. If the vehicle is left with a parking attendant, only the ignition key is to be left. Drivers must honor posted speed limits. In the event of adverse driving conditions, drivers are required to reduce speed to a safe operating speed that is consistent with the conditions of the road, weather, light, and traffic. Drivers are required to maintain a safe following distance at all times. Drivers should keep a two (2) second interval between their vehicle and the vehicle immediately ahead. During slippery road conditions, the following distance should be increased to at least four (4) seconds. Drivers must yield the right of way at all traffic controls, signals, and signs requiring them to do so. Drivers should also be prepared to yield for safety’s sake, at anytime. Pedestrians and bicycles in the roadway always have the right of way. Drivers are required to stay to the right at all times, except when passing in a legal passing zone or preparing for a left-hand turn. All drivers and passengers, operating or riding in company vehicles, must wear seat belts and shoulder straps, if provided (even if air bags are installed). Failure to comply with this regulation will result in immediate termination.

Physical Job Requirements

Job Title	Job Coach/Program Assistant
Date
Supervisor Name

Section I (to be completed by supervisor)

1. Percent of time spent for each activity:

Sitting	10	%
Standing	20	%
Moving about	70	%

2. Does the job require:

Talking	X	Yes	No
Hearing	X	Yes	No
Seeing	X	Yes	No
Manual dexterity	X	Yes	No
Finger dexterity	X	Yes	No
Driving a motor vehicle	X	Yes	No
Other		Yes	No

3. Job requires:

	Never	Occasionally	Frequently
Bend/stoop			X
Climb stairs			X
Reach above shoulder level			X
Crouch			X
Kneel			X
Balance			X
Push/pull			X
Restraining		X

4. Job requires carrying:

	Never	Occasionally	Frequently
Up to 10 lbs.			X
10 to 50 lbs.			X
50 or more lbs.		X

5. Job requires lifting:

	Never	Occasionally	Frequently
Up to 10 lbs.			X
10 to 50 lbs.			X
50 or more lbs.		X

Additional comments:

Section II to be completed by conditional hire

Is there anything that would hinder you from performing the physical requirements described in Section 1 of this form?

Yes No

If yes, please identify which aspects of the job would pose a problem for you.

I certify that my answers are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment 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 as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable 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 acknowledge in writing by an authorized executive of this 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.

I Agree