Employment - Nu Horizons Of Southern Minnesota

Order Number

Name

Address

City

State

Zip

Phone

Social Security Number

Date Available For Employment

If employed and under 18, can you furnish a work permit? *

Yes No

Have you ever been employed by this company? *

Yes No

Are you employed now? *

Yes No

May we contact your present employer? *

Yes No

If yes, give name

Are you prevented from lawfully becoming employed in this country because of visa or immigration status? *

Yes No

Type of work desired

If applying for a position where driving is required, do you have a valid driver’s license in this state? *

Yes No

License #

Can you perform the essential functions of the job(s) for which you are applying? *

Yes No

Are you available to work *

Full-Time Part-Time Overtime

Have you been convicted of a felony?

Yes No This question does not need to be answered due to 2014 MN law

If yes, please explain

Please note that a “Yes” answer will not bar you from consideration for employment.

Elementary

Years Completed

Course Of Study

Secondary

Years Completed

Course Of Study

College

Years Completed

Course Of Study

Graduate School

Years Completed

Course Of Study

Special Skills, Qualifications, and Considerations

List three (3) non-relatives who are familiar with your qualifications, work history, and ability.

Name

Occupation/Relationship

Years Known

Telephone

Name

Occupation/Relationship

Years Known

Telephone

Name

Occupation/Relationship

Years Known

Telephone

Employer1

Employer

Supervisor’s Name

Address

Your Job Position

Telephone Number

Employed from

Employed to

Your Salary: Starting/Ending

Duties

What did you like most about your job?

Reason for Leaving

Employer2

Employer

Supervisor’s Name

Address

Your Job Position

Telephone Number

Employed from

Employed to

Your Salary: Starting/Ending

Duties

What did you like most about your job?

Reason for Leaving

Employer3

Employer

Supervisor’s Name

Address

Your Job Position

Telephone Number

Employed from

Employed to

Your Salary: Starting/Ending

What did you like most about your job?

Reason for Leaving

I CERTIFY that the above answers are true and complete to the best of my knowledge,!
I authorize Nu Horizons of Southern Minnesota, LLC, to investigate any statement contained in this application, and to obtain a credit report on me (and my company if this application is for reselling by a company) as necessary to determine my qualification. I understand that this application is not and is not intended to be any kind of contract or agreement, In the event of employment, I understand that any false or misleading information given in my
application, correspondence, discussions or interview, may result in immediate termination. I understand also, that I am required to abide by all rules, regulations and policies of Nu Horizons of Southern Minnesota, LLC.

I have read, understand, and agree with the above.

Signature Of Applicant

Date

This application is valid for only (90) days from the date I signed. If I want to be considered for job openings more than ninety (90) days from date signed. I will submit a new application.

This Fair Credit Reporting Act (FCRA) provides individuals with certain rights regarding consumer reports and places certain obligations on employers using consumer reports for employment-related purposes. Consistent with the FCRA’s requirements, this notice is provided to you in order to inform you that QUALITY EXTRUSION may, for employment-related requirements purposes (e.g., evaluating you for initial employment, promotions, transfers, assigned duties, retention as an employee, etc.), obtain from a consumer reporting agency one or more consumer reports containing financial information, criminal record information, driving record information, and/or other relevant information about you. QUALITY EXTRUSION will not obtain a consumer report without your signature below authorizing us to obtain one or more consumer reports.

Authorization to Obtain Consumer Reports
I hereby acknowledge that I have read and understand the contents of the above notice and, by signing below, specifically authorize QUALITY EXTRUSION to obtain one or more consumer reports on me for employment-related purposes as indicated above.

Signature2

Date2

Attach Resume

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