Employment Application

It is our policy to comply with all applicable state and federal laws prohibiting discrimination in employment based on race, age, color, sex, religion, national origin or other protected classifications.

Step 1 of 6

Name*
First Middle Last
Date*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Email Address*
Phone Number*
Secondary Phone Number*
Are you over 18 years old?*
- Yes
- No
Are you authorized to work in the United States on an unrestricted basis?*
- Yes
- No

Employment Experience

List employment for the past 10 years, starting with present job. Include military experience
Employment 1
Company Name
Specific Duties
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Job Title
Supervisor
Reason for Leaving
Date Began
Date Ended
Employment 2
Company Name
Specific Duties
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Job Title
Supervisor
Reason for Leaving
Date Began
Date Ended
Employment 3
Employer Name
Specific Duties
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Job Title
Supervisor
Reason for Leaving
Date Began
Date Ended

References
List four individuals not related to you that have known you for at least one year.
Business/Employers Reference 1
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone
Home Phone
Cell Phone
Business/Employers Reference 2
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone
Home Phone
Cell Phone
Personal Reference 1
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone
Home Phone
Cell Phone
Personal Reference 2
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone
Home Phone
Cell Phone
May we contact your present employer?
- Yes
- No
- N/A
If yes, please provide the following information:
Name, Title, Address, and Work Phone

Upload Resume
Accepted file types: pdf, doc, docx, jpg, jpeg.
Max. file size: 64 MB.
Applicant's Statement & Agreement

I certify that all statements made by me on this application are true and complete to the best of my knowledge and that I have withheld nothing which, if disclosed, would affect this application unfavorably.

I authorize my previous employers, schools for persons named as references to give any information regarding employment and educational records. I agree that the DAC and my previous employers shall not be held liable in any respect if a job offer is not extended, is withdrawn or my employment is terminated because of false statements, omissions or answers made by me on this application. If I am employed by the DAC, I will comply with all rules and regulations as set forth in any communication distributed to employees.

I understand that, if hired, I am entering into a co-employment relationship whereas Winona DAC is my worksite and directing employer, and Winona DAC is my administrative employer. I agree that the benefit plans offered in my co-employment package are those of Winona DAC and are the only benefit plans in which I am eligible to participate. I further agree that I will not be eligible for other benefits (if any) offered to other non co-employees of Winona DAC, now or in the future. I understand, if hired, I may be required to sign a non-compete/non-disclosure agreement. This application will be kept in a current file for thirty days. If not contacted during that period of time, it may be necessary to complete another application to receive further employment consideration.

In compliance with the Immigration Reform and Control Act of 1986, I understand that I will be required to provide approved documentation that verifies my right to work in the United States on my first day of employment. I am in receipt of a list of approved documents which have been supplies with this application. Minnesota Statues, chapter 245A, and Minnesota Rule 11 require the Department of Human Services (DHS) to perform a background studies of individuals working in positions allowing direct contact with persons receiving services from programs licensed by DHS. The requested information will be used to perform a background study that will include, but will not be limited to, a review of criminal conviction records held by the Bureau of Criminal Apprehension and cases of substantiated abuse and neglect of vulnerable adults and maltreatment of minors. The statute and rule require that I must provide sufficient information on my first day of employment to ensure an accurate study. Refusal to provide the necessary information will result in disqualification and thus I can not be employed by the DAC. The information received as part of the background study is classified as private information and can not be released to anyone without my written consent. If I am found to have a disqualifying characteristic, the DAC will only be told that I am disqualified and will not be told what the information was that caused my disqualification. My employment with the DAC can not be finalized until the results of the background check are returned. I have the right to appeal if a disqualification notice is received.

I understand that employment at the DAC is "at will", which means that either I or the DAC can terminate the employment relationship at any time, with or without prior notice, and for any reason not prohibited by statute. All employment is continued on that basis. I understand that no supervisor or manager other than the Executive Director has any authority to alter the foregoing.

I hereby acknowledge that I have read and understand the above statements.
Name*
Please type your name to signify a signature
Date*
MM slash DD slash YYYY

Step 1 of 6

Education: High School

Education: Trade School

Education: College/University

Employment Experience

Employment 1

Employment 2

Employment 3

References

Business/Employers Reference 1

Business/Employers Reference 2

Personal Reference 1

Personal Reference 2

Applicant's Statement & Agreement

1721 West Service Drive,
Winona, MN 55987

(507) 452-1798

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Employment Application

Step 1 of 6

Education: High School

Education: Trade School

Education: College/University

Employment Experience

Employment 1

Employment 2

Employment 3

References

Business/Employers Reference 1

Business/Employers Reference 2

Personal Reference 1

Personal Reference 2

Applicant's Statement & Agreement

1721 West Service Drive, Winona, MN 55987

(507) 452-1798

Sign up for our monthly email newsletter

1721 West Service Drive,
Winona, MN 55987