1325 Eagandale Court Suite #120
Eagan, MN 55121
(651) 688-7173
Job Application
Position Desired ____________________
Full Time _____ Number of Hours Desired _____________
Part Time _____ Number of Hours Desired _____________
Today’s Date _________________ Date Available to Start _________________
Name __________________________________________________________________
Last First Middle
PERSONAL
Name:_______________________________________________________________________
Last First Middle
Address: _____________________________________________________________________
Street City State Zip
Telephone Number: (Home) ____________________________
(Cell) _____________________________
Are you over the age of 18? Yes_____ No _____
What is your schedule preference? _________________________________________
Will you work Shifts? _______ Weekends? _________ Holidays? _______
Is there any reason you cannot be at work every day? ________ Be on time? ______
Have you ever been convicted of a felony within the last seven years? Yes _____ No _____
If yes explain:
___________________________________________________________________________________________
_________________________________________________
Do you have a valid class D Drivers License? Yes______ No_______
EDUCATION
Name Facility Name Type of Degree & Date Major Subject
Everyday Living
Received
High School Name:
State:
College or University Name:
State:
Vocational, Business, Name:
or Technical School State:
Other Name:
State:
REFRENCES (not including members of your family)
Name Occupation Years known Phone Number
1.
2.
3.
WORK EXPERIENCE (include U.S. Military Service) List complete employee history, but do not
provide dates of employment for jobs held more than five years ago.
Company Name __________________________ Date of employment: From ______ to ______
Street Address ____________________________________ Job Title _____________________
City ________________ State ___________________ Zip ______________
Telephone Number ___________________
Name of Supervisor _____________________________ Title ____________________
Starting Salary _____________ Ending Salary ______________
Hours worked/wk ___________
Job Duties _____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Reason for leaving ______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Company Name __________________________ Date of employment: From ______ to ______
Street Address ____________________________________ Job Title _____________________
Everyday Living
City ________________ State ___________________ Zip ______________
Telephone Number ___________________
Name of Supervisor _____________________________ Title ____________________
Starting Salary _____________ Ending Salary ______________
Hours worked/wk ___________
Job Duties _____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Reason for leaving ______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Company Name __________________________ Date of employment: From ______ to ______
Street Address ____________________________________ Job Title _____________________
City ________________ State ___________________ Zip ______________
Telephone Number ___________________
Name of Supervisor _____________________________ Title ____________________
Starting Salary _____________ Ending Salary ______________
Hours worked/wk ___________
Job Duties _____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Reason for leaving ______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Company Name __________________________ Date of employment: From ______ to ______
Street Address ____________________________________ Job Title _____________________
City ________________ State ___________________ Zip ______________
Telephone Number ___________________
Name of Supervisor _____________________________ Title ____________________
Starting Salary _____________ Ending Salary ______________
Hours worked/wk ___________
Job Duties _____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Reason for leaving ______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Have you ever been terminated from employment? Yes _____ No _____
Everyday Living
If yes, explain: _________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Special trainings or job skills:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Awards or Achievements:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
READ CAREFULLY BEFORE SIGNING
If employed, I understand that in a period of low census or caseload. I may be required to take
time off without pay according to Everyday Living AFCs’ needs or I may be reassigned to
another house.
Print Name: ________________________Signature:_____________________Date: ________
Everyday Living