763-662-2836
Every Day 9:00 AM - 5:00 PM
13892 37th Street, Clear Lake, MN 55319
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Personal Information
Name:
Mailing Address:
Email:
Employment Desired
Position(s) applied for:
Will you accept employment of: Full-timePart-timeCasual/On-call
Are you 18 years of age or older: YesNo
Education
Highest grade completed: Grade SchoolHigh SchoolAssociates DegreeBachelors DegreeMasters DegreeDoctorate
Grade School
Completed YesNo
Professional Licenses and/or Certifications
License and/or Certification #1
License and/or Certification #2
License and/or Certification #3
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Employment Record (list last or present position first)
Employer 1
Employer (company name)
Immediate supervisor name
Job title
Street address
Employment date (mo. & yr.)
City, State, Zip
Phone
Reason for leaving
Summarize your job duties
Is there any reason why you would not want us to contact this employer?
Employer 2
Employer 3
Personal References (Do not include Relative or Former Employers)
Name
Phone#
Business
Years Acquainted
TB Screening
Are you willing to have a 2-step Mantoux administered or a chest x-ray for TB Screening? (paid for by Lange Board & Room) YesNo
Background Study Information Request
Gender
Date of Birth
Driver License or State ID #
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Race
SSN
Other Last Name
Other First Name
State Born In
Have you lived in other states within last 5 years YesNo
If yes, full address
By my signature below, I promise that the information provided in this employment application ( and in any related documentation or interview) is true and complete, and I understand that any false or misleading information or significant omissions may disqualify me from further consideration from employment, and may lead to my dismissal from employment if discovered at a later date.
Applicant’s Signature
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