7400 Laurel Ave. Golden Valley, MN 55426

WorkAbilities, Inc.

7400 Laurel Ave. Golden Valley, MN 55426

APPLICATION FOR EMPLOYMENT

Please complete entire application even if you attach a resume. Print or type all requested information.

Return by U.S. Mail, E-mail or Fax: 763.541.0415

Name:______Other Names Known By:

Address:______City, State:______Zip:______

Telephone: (H)______(W)______

Cell Phone:______E-mail:______

EDUCATION & TRAINING

Do You Have A High School Diploma/GED? ______Yes ______No
Do You Have A Bachelor’s Degree? ______Yes ______No
School Dates Attended Degree Major Minor
______
______

EMPLOYMENT HISTORY

List your previous employment and/or volunteer experience related to human services. Begin with most recent related work experience; attach additional sheets if necessary.
1. Employer:______Job Title: ______
Address:______Telephone:______
______
Number of hours/week:______Dates Worked: ____/____/____ To ____/____/____
Month Day Year Month Day Year
Job Responsibilities: ______
Reason For Leaving: ______
2. Employer:______Job Title: ______
Address:______Telephone:______
______
Number of hours/week:______Dates Worked: ____/____/____ To ____/____/____
Month Day Year Month Day Year
Job Responsibilities: ______
Reason For Leaving: ______
3. Employer:______Job Title: ______
Address:______Telephone:______
______
Number of hours/week:______Dates Worked: ____/____/____ To ____/____/____
Month Day Year Month Day Year
Job Responsibilities: ______
Reason For Leaving: ______
4. Employer:______Job Title: ______
Address:______Telephone:______
______
Number of hours/week:______Dates Worked: ____/____/____ To ____/____/____
Month Day Year Month Day Year
Job Responsibilities: ______
Reason For Leaving: ______

ADDITIONAL APPLICANT INFORMATION

You may be required to transport clients and you will need to possess a valid MN Drivers License.
# ______Expiration: ______
Are you Legally Eligible for Employment in the U.S.? _____Yes _____No
*Proof of U.S. Citizenship immigration status will be required upon employment.
Direct Service positions at WorkAbilities, Inc. involve rigorous physical activities which may include the physical ability to (1) stand and walk for up to seven hours a day; (2) perform two-person lifts of adult clients throughout the day, including squatting, pivoting, flexing and kneeling; (3) independently roll, position or complete ROM/Stretching exercises with clients (4) push clients in wheelchairs on both level and inclined surfaces. (5) engage in repetitive lifting or other physical movements in care of clients or in fulfilling production demands.
Are you with or without reasonable accommodation, able to perform all of these job functions?
_____Yes _____No
Employment Offer is contingent on the employee demonstrating the safe ability to perform essential tasks on a Physical Abilities Test.
Employment is contingent on successful completion of a background study and clearance from the DHS Background Studies Unit.

REFERRAL SOURCE

_____Website or Facebook:______
_____Employee of WorkAbilities: ______
_____Other: ______

PLEASE READ:

WorkAbilities, Inc. is an equal opportunity employer. WorkAbilities, Inc. does not discriminate in employment, and no question on this application is used for the purpose of limiting or excluding any applicant’s consideration for employment on a basis prohibited by local, state, or federal law.

I give WorkAbilities, Inc. the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability WorkAbilities, Inc. and its representatives for seeking such information and all other persons, corporations, or organizations for furnishing such information.

It is understood and agreed that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from WorkAbilities, Inc.’s services if I have been employed. Furthermore, I understand that just as I am free to resign at any time, WorkAbilities, Inc. reserves the right to terminate my employment at any time, with or without cause, and without prior notice. I understand that no representative of WorkAbilities, Inc. has the authority to make any assurances to the contrary.

Acknowledgement of Applicant: ______Date: ______

PI 112 Application for Employment 2/13 Revised description of physical activities to be performed.