Job Application | Community Living Options

Position you're applying for *

Name *

First

Last

Social Security Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Are you 18 years or older? *

Yes
No

Have you previously worked for Community Living Options? *

Yes
No

How did you hear about CLO? *

Newspaper
Friend
Other

Referred By

Are you legally eligible for employment in this country? *

Yes
No

Are you employed now? *

Yes
No

Type of employment desired *

Full Time
Part Time
Temporary
Seasonal/School Break

Date you can start *

Salary Desired *

Are you able to meet the attendance requirements of the position? *

Yes
No

Education Level

List up to 3 schools you attended or are attending.

Name of School

Location of School

How long did you attend?

Did you graduate?

Yes
No

Subjects Studied

School #2

Name of School

Location of School

How long did you attend?

Did you graduate?

Yes
No

Subjects Studied

School #3

Name of School

Location of School

How long did you attend?

Did you graduate?

Yes
No

Subjects Studied

General Information

Special Training

Subject of Special Training

Special Skills

Please provide a list of your last 3 employers, starting with the most recent

Name of Employer

Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Title

Starting Date

Leaving Date

Starting Salary

Ending Salary

May we contact your supervisor?

Yes
No

Job Description

Reason for Leaving

Employer #2

Name of Employer

Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Title

Starting Date

Leaving Date

Starting Salary

Ending Salary

May we contact your supervisor?

Yes
No

Job Description

Reason for Leaving

Employer #3

Name of Employer

Address

Address Line 1

Address Line 2

City

State

Zip Code

Job Title

Starting Date

Leaving Date

Starting Salary

Ending Salary

May we contact your employer?

Yes
No

Supervisor's Phone

Job Description

Reason for Leaving

References

Please use three persons you are not related to, whom you have known at least one year

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Business/Profession *

Years Known *

Phone *

Reference #2

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Business/Profession *

Years Known *

Phone *

Reference #3

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Business/Profession *

Years Known *

Phone *

Service Record

Branch of Service

Discharge Date

Rank

Other service information

Authorization

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give CLO any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise and release CLO from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of CLO has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized CLO representative.

Authorization Agreement *

I agree to the above statement.

Release of Information Waiver

In consideration of my employment with Community Living Options (CLO), I hereby acknowledge that as part of my employment or my application for employment, the Minnesota Department of Human Services (DHS), will conduct a background study on me and determine whether I am qualified to work in a DHS Licensed facility, as provided in state law and rule. I understand that my failure to cooperate is grounds to terminate or deny employment under MN Statue 245A.04, Subd. 4. I also understand that state law authorizes DHS or County to receive conviction data, certain juvenile data, arrest information, investigation information, substantiated reports of abuse or neglect of adults or children and other information.

I hereby authorize DHS or County Social Services to release all information received as part of the background study to CLO. I further acknowledge that my employment is conditioned on initial and continued qualifications as determined by the Commissioner of Human Services, and that determination of disqualification is cause for immediate dismissal. I hereby release CLO, its assigns and successors from any and all liability arising from such dismissal resulting from the Commissioner’s determination.

Waiver Agreement *

I agree to the above waiver.

Equal Employment Opportunity

In order to provide equal employment and advancement opportunities to all individuals, employment decisions at CLO will be based on merit, qualifications, and abilities, CLO does not discriminate in employment opportunities or practices on the basis of race, color, creed, religion, sex, national origin, age, disability, marital status, sexual orientation, status with regards to public assistance, or any other characteristic protected by law. CLO will make reasonable accommodations for qualified individuals with known disabilities unless doing would result in an hardship.

Equal Opportunity Agreement *

I have read the above statement.

Online Job Application

Education Level

School #2

School #3

General Information

Please provide a list of your last 3 employers, starting with the most recent

Employer #2

Employer #3

References

Reference #2

Reference #3

Service Record

Authorization

Release of Information Waiver

Equal Employment Opportunity

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