SEEK Home, Inc. - Application For Employment
We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital, or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status. (E. O. E.)
Date of Application *
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Position(s) Applied For *
Required
How did you hear about SEEK Home, Inc.? *
Your answer
Applicant's Full Name *
Enter full name
Your answer
Address *
Your answer
Telephone *
Your answer
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)
Have you filed an application with SEEK Home, Inc. previously? If Yes, give date.
Your answer
Have you ever been employed by SEEK Home, Inc. previously? If Yes, give date.
Your answer
Are you employed now?
May we contact your current employer?
On what date are you available to work?
MM
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DD
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YYYY
Expected Salary *
Your answer
Are you available to work (Check all that apply): *
Required
Please note any specific scheduling conflicts:
(i.e. school schedule, other employment, request to work a specific weekend, etc.)
Your answer
Do you have a valid drivers license? *
(Driving record will be check and employment is contingent on proof of good driving record)
Required
Have you been convicted of a felony within the last 7 years? *
(A criminal background study will be completed through the Department of Human Services; qualified candidates are eligible for employment)
Required
Please explain conviction if applicable:
Your answer
Are you a veteran of the U.S. Military Service?
If yes, what branch?
Your answer
Special employment notice to Disabled Veterans, Vietnam Era Veterans, and Individuals with Physical or Mental Handicaps:
Government contractors are subject to 38 USC 2012 of the Viet Era Veterans Readjustment Act of 1974 which requires that they take affirmative action to employ and advance in employment qualified disabled veterans of the Vietnam Era, Section 503 of the Rehabilitation Act of 1973, as amended, which requires government contractors to take affirmative action to employ and advance in employment qualified handicapped individuals. If you are a disabled veteran, or have physical or mental handicap you are invited to volunteer this information which will be treated as confidential. Failure to provided this information will not jeopardize or adversely affect your consideration for employment.
Please sign and date below:
You agree to share your response with us, SEEK Home Inc.
Your answer
Employment experience. Please include employer name, telephone, address, job title, supervisor, dates employed, duties performed, and reason for leaving:
Start with your present job or last job.
Your answer
Employment experience. Please include employer name, telephone, address, job title, supervisor, dates employed, duties performed, and reason for leaving:
Start with your present job or last job.
Your answer
Employment experience. Please include employer name, telephone, address, job title, supervisor, dates employed, duties performed, and reason for leaving:
Start with your present job or last job.
Your answer
Special skills and qualifications:
Summarize special skills and qualifications acquired from employment or other experience:
Your answer
Education: Please include school name, years completed/degree, and course of study.
(start with high school, college/university, and then graduate/professional if applicable)
Your answer
Honors received:
(state any additional information you feel may be helpful to us in considering your application)
Your answer
Applicant's statement. Please sign and date below:
I certify that answers given herein 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 not to exceed 45 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. In the event that the applicant agrees to accept the position with SEEK Home Inc., the applicant and SEEK Home, Inc. agree that the employment relationship between company and employee is an at will relationship and that the employment relationship and compensation can be terminated, with or without cause, and with or without notice at any time, at the option of either the company or the employee. 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.
Your answer
Conditions of employment/work readiness form: Each prospective employee of SEEK Home Inc. shall verify work readiness by agreeing to meet the following conditions of employment. These conditions of employment are necessary to meet state and federal regulations governing residential service providers for adults with developmental disabilities, such as SEEK Home Inc. Please sign and date below.
1. Each prospective employee shall complete the Rule 11 background study and must not be disqualified from employment in this field based on background study results. Information regarding the background study procedure and disqualifying convictions is available through the program director. 2. Each prospective employee will have a driving record review and must be approved by SEEK management prior to driving company vehicles. Inability to drive company vehicles because of insurance denials, multiple moving violations, suspensions or revocations of driving privileges and failure to pass SEEK Home's "on the road" skills test may disqualify an individual from employment or modify the terms and conditions of such employment. 3. Each prospective employee must be able, with or without reasonable accommodations, to perform essential functions of the positions for which he/she is applying. This would include, in some situations, the ability to perform two-person lifts as required for the personal care and safety of our consumers. The physical ability to lift consumers who reside in our homes, with assistance, may in some cases by an essential function of the position available.
Your answer
Employee screening form. This is to be used by individuals, corporations, partnerships, or governmental units to screen employees for qualification standards required for licensed Adult Foster Homes. (95555.6125 subpart 4)
Each applicant must answer the following questions: Are you willing to disclose your convictions and criminal history?
Do you have a conviction of, or are you awaiting a trial for, or do you admit to any of the following crimes?
Possession, use, sale, manufacture, and/or distribution of illegal drugs and simulated illegal drugs? (M.S. sections 152.09, 152.096, 152.097)
Murder, manslaughter, aiding a person in suicide or attempted suicide?
(M.S. sections 609.185 to 609.215)
Assault, mistreatment of persons confined, mistreatment or residents or patients, use of drugs to injure or facilitate crime, robbery, kidnapping, false imprisonment, depriving another of custodial or parental rights or abduction.
(M.S. sections 609.221 to 609.265)
Coercion, attempt to coerce, interfering with religious observance, leaving the state to evade establishment of paternity, prostitution and related offenses, or criminal sexual conduct?
(M.S. sections 609.27 to 609.345)
Incest, malicious punishment of a child, or neglect of a child?
(M.S. sections 309.365, 609.377, and 609.378)
Theft, possession of shoplifting gear, bringing stolen goods into the state, receiving stolen property or embezzlement of public funds?
(M.S. sections 609.52, 609.521, 609.525, 609.53, 609.54, 609.551, 609.59)
Arson, burglary, or possession of burglary tools?
(M.S. sections 609.564, 609.582, 609.59)
Forgery, or aggravated forgery?
(M.S. sections 609.625 or 609.63)
Riot or terroristic threats?
(M.S. sections 609.71 or 609.713)
Indecent exposure, or use of minors in sexual performance?
(M.S. sections 617.23, 617.246)
Have you ever been convicted of, charged with, or subject of an investigation for, or do you admit to abusing or neglecting an adult or child?
(M.S. sections 625.556 and 656.557)
Have you ever had your parental right involuntarily terminated within the past five years?
(M.S. sections 260.221, paragraph B)
Do you abuse prescription drugs, or use controlled substances, or alcohol to the extent that it would interfere with the health, safety, and rights of residents of the adult foster home?
(M.S. Chapter 152)
Please note: At any time during the licensed term of the adult foster home, a physical, mental health, chemical dependency, or criminal history evaluation of the operator or direct support professional may be required if there is reasonable cause to believe the qualification requirements have not been met or that the operator or direct support professional cannot care for the resident.
I hereby affirm that the foregoing statements are accurate, complete, and true to the best of my knowledge. I understand that if I give false information, I may not be a direct support professional in a licensed foster home. Please sign and date below:
Your answer
1. I possess a valid driver's license?
2. I have had less than 2 traffic violations in the last three years?
3. I have had ZERO DUI violations in the last three years?
4. I understand that I cannot drive under any circumstances unless my record has been cleared?
5. I am willing to furnish a copy of my certificate of insurance to SEEK Home, Inc.
6. Upon hiring, I understand that I will not use my personal vehicle to transport clients. This is not part of my responsibilities.
7. I understand that I am responsible for informing SEEK Home, Inc. supervisors of any changes in the status of my auto liability insurance or licensing status.
8. I understand that I will not operate an uninsured vehicle at any time during a shift, defined by the hours on my timecard.
I have read and understand this policy and it's conditions:
Please sign and date below
Your answer
RELEASE FOR REFERENCE
Please give name, address, and phone number of current or past employer. By giving this information you are authorizing the release of information related to previous work performance and duties performed.
Your answer
RELEASE FOR REFERENCE
Please give name, address, and phone number of current or past employer. By giving this information you are authorizing the release of information related to previous work performance and duties performed.
Your answer
RELEASE FOR REFERENCE
Please give name, address, and phone number of current or past employer. By giving this information you are authorizing the release of information related to previous work performance and duties performed.
Your answer
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