Employment Application If you experience technical difficulties, please note the error message and contact Cindy at 507-226-0712 or cverdick@hiawathahomes.org. Step 1 of 11 9% Personal InformationName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Do you have an email address?*YesNoEmail* Do you have a phone?*YesNoPhone*Have you ever applied to Hiawatha Homes in the past?*YesNoHave you ever worked for Hiawatha Homes in the past?*YesNoPlease indicate the department/house you were most recently employed at:*Please indicate the time period you were previously employed with Hiawatha Homes:*If hired by Hiawatha Homes, can you provide proof that you're eligible to work in the United States?*YesNoDo you have a current AND valid Driver's License?*YesNo Position InformationPosition Applied For*Select OneDirect Support Aide (Age 17, turning 18 within 60 days)Direct Support Professional (Ages 18 and Up)Team LeaderHouse CoordinatorProgram DirectorLicenced Practical Nurse (LPN)Registered Nurse (RN)OtherSpecific Position:*If hired for a Direct Support Aide position at Hiawatha Homes, can you provide verification that you will be 18 years of age within 60 days?*YesNoIf hired at Hiawatha Homes, can you provide verification that you are at least 18 years of age or older?*YesNoEmployment Status Desired* Full Time (30 hrs/wk or more) Part Time (29 hrs/wk or less) Seasonal (Summer Only) Reverse Seasonal (School Year Only) On-Call Wage/Salary Expectation:*Date Available to Start*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please indicate how you learned about employment at Hiawatha Homes.*Select OneCareer FairCurrent EmployeeFamily/FriendFormer EmployeeInternetNewspaperRadioSchoolTVWalk InCurrent Employee's Name:*Former Employee's Name:*Internet Source* Educational BackgroundPlease list your academic, vocational, or professional education, and the public and/or private schools you’ve attended, starting with your most recent experience:*SchoolLocationMajor/Course of StudyType of Experience (Certificate, Degree, etc.)Level of Completion Employment HistoryDo you have any previous employment history?*YesNoMost Recent Employer*Most Recent Employer's Phone Number*Most Recent Employer's Location (City, State)*Most Recent Job Title*Most Recent Supervisor's Name and Title*Most Recent Starting Date of Employment*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Still employed at most recent position?*YesNoMost Recent Ending Date of Employment*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Most Recent Hours Per WeekSummarize the type of work performed and job responsibilities of most recent position:*Most Recent WageReason for Leaving Most Recent Position*May we contact this most recent employer?YesNoIf no, please explain why not:*Do you have additional employment history?*YesNo2nd Most Recent Employer*2nd Most Recent Employer's Phone Number*2nd Most Recent Employer's Location (City, State)*2nd Most Recent Job Title*2nd Most Recent Supervisor's Name and Title*2nd Most Recent Starting Date of Employment*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Still employed at 2nd most recent position?*YesNo2nd Most Recent Ending Date of Employment*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119202nd Most Recent Hours Per WeekSummarize the type of work performed and job responsibilities at 2nd most recent position:*2nd Most Recent Most Recent WageReason for Leaving 2nd Most Recent Position*May we contact this 2nd most recent employer?*YesNoIf no, please explain why not:*Do you have additional employment history?*YesNo3rd Most Recent Employer*3rd Most Recent Employer's Phone Number*3rd Most Recent Employer's Location (City, State)*3rd Most Recent Job Title*3rd Most Recent Supervisor's Name and Title*3rd Most Recent Starting Date of Employment*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Still employed at 3rd most recent position?*YesNo3rd Most Recent Ending Date of Employment*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119203rd Most Recent Hours Per WeekSummarize the type of work performed and job responsibilities at this 3rd most recent position:*3rd Most Recent Most Recent WageReason for Leaving 3rd Most Recent Position*May we contact this 3rd most recent employer?*YesNoIf no, please explain why not:*Do you have additional employment history?*YesNo4th Most Recent Employer*4th Most Recent Employer's Phone Number*4th Most Recent Employer's Location (City, State)*4th Most Recent Job Title*4th Most Recent Supervisor's Name and Title*4th Most Recent Starting Date of Employment*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Still employed at 4th most recent position?*YesNo4th Most Recent Ending Date of Employment*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119204th Most Recent Hours Per WeekSummarize the type of work performed and job responsibilities at this 4th most recent position:*4th Most Recent Most Recent WageReason for Leaving 4th Most Recent Position*May we contact this 4th most recent employer?*YesNoIf no, please explain why not:*Do you have additional employment history?*YesNo5th Most Recent Employer*5th Most Recent Employer's Phone Number*5th Most Recent Employer's Location (City, State)*5th Most Recent Job Title*5th Most Recent Supervisor's Name and Title*5th Most Recent Starting Date of Employment*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Still employed at 5th most recent position?*YesNo5th Most Recent Ending Date of Employment*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119205th Most Recent Hours Per WeekSummarize the type of work performed and job responsibilities at this 5th most recent position:*5th Most Recent Most Recent WageReason for Leaving 5th Most Recent Position*May we contact this 5th most recent employer?*YesNoIf no, please explain why not:* Personal/Professional References Please provide AT LEAST THREE references, and do not list family members or relatives.*Personal or Professional?Name and RelationshipPhone NumberEmail AddressIs this a Hiawatha Homes employee? Supplemental Questions Why are you interested in a career with Hiawatha Homes?*Describe any job-related experiences you have had that make you a good candidate for this position.*How do you respond when you have a lot of work to do and not enough time or assistance to get it all done?*Tell us about a time when something unplanned happened at work. What was the situation and how did you handle it?*Provide a specific example of something you have done that demonstrates you are a team player.*Do you have any other relevant job skills or qualities you would like us to know about?* Applicant Consent Statement By my signature below, I promise that the information provided in this employment application is true and complete, and I understand that any false or misleading information or significant omissions may disqualify me from further consideration for employment, and may lead to my dismissal from employment, if observed at a later date, no matter how long I have been employed. I authorize, without reservation, Hiawatha Homes to contact and obtain information from all reference (personal and professional), employers, public agencies, licensing authorizes and educational institutions and to otherwise verify the accuracy of all information provided by me in this employment application, resume, or job interview. I understand that, if I am hired by Hiawatha Homes, I will be employed on an at-will status. As an at-will employee, I understand that I may terminate my employment at any time, for any reason. Similarly, if I am hired, I understand that Hiawatha Homes will have the right to terminate my employment at any time, for any reason, with or without cause, notice or prior warning or discipline. I understand that no Hiawatha Homes supervisor or manager has the authority to offer or promise anything other than at-will employment, and no subsequent transfer, promotion or change in my employment will affect my at-will employment status. Hiawatha Homes is an equal employment opportunity employer and will not discriminate against an applicant or employee on any grounds protected under federal, state, or local law. None of the questions in this application are intended to elicit information regarding any protected characteristic(s), nor imply any limitation, illegal preference or discrimination based upon non-job-related information or protected characteristic(s). Hiawatha Homes complies with all applicable legal requirements in its hiring process and related tests and background checks. I understand that this employment application does not create a contract of employment. I understand that my employment application will remain active for 90 days from the date it was submitted. I understand that partially completed employment applications will not be processed for employment opportunities at Hiawatha Homes.By typing your name you indicate that you have read, understood and agree to the above information.Application Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Cover Letter and Resume Thank you for your interest in joining the Hiawatha Homes team. If you wish to submit a cover letter and/or resume, please upload it below or email it to Cindy Verdick, Recruitment & Training Specialist, at cverdick@hiawathahomes.org.Cover Letter (.doc, .docx or .pdf)Accepted file types: pdf, doc, docx.Resume (.doc, .docx or .pdf)Accepted file types: , pdf, doc, docx. Voluntary Affirmative Action Survey As an affirmative action employer, we must monitor our equal employment opportunity and affirmative action program, and report the results to government agencies. Please help us gather this information by identifying your sex, race or ethnicity, and disability status on this form. Providing this information is completely voluntary. If you choose not to provide some or all of this information, you will not be subject to any negative or adverse treatment. The information you provide will be used only to monitor our compliance with equal opportunity laws and regulations and for no other purpose.* When we receive this form, we will immediately place it in a confidential file separate from your application. If you wish, you may mail this form to us in an envelope separate from the one that contains your application.Gender*MaleFemaleI do not wish to identifyRace/National Origin: Please select the category that best identifies your race/ethnicity.*Select OneI do not wish to identifyHispanic or LatinoCaucasianBlack or African AmericanNative Hawaiian or Other Pacific IslandAsianAmerican Indian or Alaska NativeTwo or More Races Voluntary Self-Identification of Disability Why are you being asked to complete this form? Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities. To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way. If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier. How do I know if I have a disability? You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to: Disabilities include, but are not limited to: Blindness, Autism, Bipolar Disorder, Post-Traumatic Stress Disorder (PTSD), Deafness, Cerebral Palsy, Major Depression, Obsessive Compulsive Disorder, Cancer, HIV/AIDS, Multiple Sclerosis (MS), impairments requiring the use of a wheelchair, Diabetes, Schizophrenia, Missing limbs or partially missing limbs, Intellectual Disability (previously called mental retardation), Epilepsy, Muscular Dystrophy.Disability Status: Please select one of the options below:*I do not wish to answer.Yes, I have (or previously have had) a disability.No, I do not have a disability. Reasonable Accommodation Notice Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment. [1] Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.Please indicate any reasonable accommodation needed.
