Opportunity Manor, Inc. Application for Employment

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Opportunities for employment as a direct care staff are available from Opportunity Manor Inc. and its community work site and homes. If you are interested in working in a wide variety of settings with adults with developmental disabilities, complete the application below and hit the submit button. Our Human Resources will be in contact with you as soon as possible. Opportunity Manor Inc. is an equal opportunity employer.

General Information

Full Name: MI Last:
Address:
City:
State: Zipcode:
Telephone Number:
Cell Phone Number:
Email Address:
Position seeking?
Date you can start:
(XX/XX/XXXX)
Desired Pay?
How did you hear of the position opening?
Were you referred by anyone? If so, name
Type of employment desired: Full-Time Part-Time Either
Have you applied here before? Yes No   If yes, year
Have you been employed here before? Yes No    If yes, year
Have you volunteered here before? Yes No    If yes, year
Are you seeking work study? Yes No
Are you seeking internship? Yes No   If yes, degree
Are you 18 years or older? Yes No
Are you 21 years or older? Yes No
Will you work overtime, if required? Yes No
Do you have a valid driver's license? Yes No
Are you able to lift 50 lbs? Yes No
May we contact your current employer
regarding information on this application? 		Yes No
Have you been convicted of a felony or
misdemeanor? 		Yes No
(You will not be denied employment or an interview solely because of a conviction; unless the offense is related to the position for which you are applying to.)

References

Please list references (include name, phone number, and relation)
Name Telephone Number Relation to you

Education

School Name School City & State # of years Degree/Diploma obtained

Employment History

Dates Employed
(XX/XX/XXX)		 Name &Telephone of Employer Start Wage
End Wage		 Essential Job Functions Reason for Leaving
Start:
End:
Start:
End:
Start:
End:
Start:
End:

List any position-applicable trainings, licenses, certifications, or skills:

List any additional information you would like to disclose:

You may attach a resume in PDF or MS Word format. (Max file size 2MB)

Applicant Statement

Read completely:

I certify that the information I have provided in order to apply for and secure work with the employer is true, complete, and correct.

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (I) cancel further consideration of this application, or (ii) immediately discharge me from the employer's service, whenever it is discovered.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume, or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees, or representatives, for seeking, gathering, and using such information in the employment process and all other persons, corporations, or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state, and federal laws.

I understand that the County Social Services/Minnesota Department of Human Services (DHS) will conduct a background study 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 for dismissal or deny employment under MN Statute 245A.04, sub. 3 and Minn. Rule 9543 - 30 40, subp 4. I also understand that state law authorizes DHS 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 to release all information received as part of the background study to the program. I further acknowledge that my employment is conditional on initial and continued qualification as determined by the Commissioner of Human Services and that determination of disqualification is cause for immediate dismissal. I hereby release the company, its assigns and successors from any and all liability arising from such dismissal resulting from the commissioner determination.

I understand that the Office of Inspector General will determine whether I am qualified to work for the Organization. In addition, the OIG has been given the authority to exclude from participation in Medicare, Medicaid and other Federal health care programs individuals and entities who have engaged in fraud or abuse, and to impose civil money penalties (CMPs) for certain misconduct related to Federal health care programs (sections 1128 and 115 of the Social Security Act, (the Act)). I further acknowledge that my employment is conditional on initial and continued qualification as determined by the OIG and that determination of exclusion is cause for immediate dismissal. I hereby release the company, its assigns and successors from any and all liability arising from such dismissal resulting from the OIG's determination.

If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of the employer is authorized to make any assurances to the contrary and that no implied oral or written agreements contract to the foregoing express language are valid unless they are in writing and signed by the employer's Administrator.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

***DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT COMPLETELY***

I certify that I have read, fully understand and accept all terms of the foregoing Application Statement.

Your full legal name:

Date (XX/XX/XXX):



Applicant Survey (Optional)

Opportunity Manor Inc. - An Equal Opportunity & Affirmative Action Employer

Please read carefully:
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.

Race / Ethnicity







Disability - Are you a person with a disability?

Yes No

Sex

Male

* This form is not used for employment decisions. If you have a disability and need an accommodation so that you can perform the duties of the job for which you are applying, please notify us in some other manner.


I agree that the information I have provided is truthful. I also agree that I understand that this Applicant Survey in no way determines my employment opportunities with Opportunity Manor Inc. I also understand that this form is filed privately and separately from any employment application to comply with equal opportunity laws and regulations.