EmailMe Form - The Wings of Newport Job Application

Position Applying for: *

Direct Support Professional (various hours - see below)

Front Desk Attendant

Name *

First Last

Date of Birth

MM / DD / YYYY

Phone Number *

### - ### - ####

Email *

Are you a current Zumbro House employee? *

Yes

No

If so, which site are you currently working at?

Have you ever been employed by Zumbro House? *

Yes

No

If yes, please provide dates you were employed from

MM/YYYY - MM/YYYY

Personal Information

Are you 18 Years of age or older? *

Yes

No

Address *

Street Address City State / Province / Region Postal / Zip Code

Have you ever been disqualified from working in a position serving vulnerable adults or children or been involved in a substantiated investigation, by the Dept. of Human Services or Dept. of Health? *

Yes

No

Is there anything in your background that may disqualify you you from working with children or vulnerable adults, by the Department of Human Services or Department of Health? This would include most felony and some gross misdemeanor convictions or any substantiated abuse or neglect investigations. *

Yes

No

If you answered "yes" to the above question, please explain.

Do you have a valid and unexpired driver's license (will be checked in state database)? *

Yes

No

Suspended

Minnesota Drivers License Number (required for all positions except overnight)

Are you eligible to work in the United States? *

Yes

No

Are you willing to submit to random drug testing?: *

Yes

No

POSITION/AVAILABILITY:

Date available to start work?

MM / DD / YYYY

We offer the following shifts: Please check all that you are able to work.

How did you hear about this position? (please be specific)

Do you have any additional skills or experience that Zumbro House, Inc. should be aware of? *

EDUCATION:

Level of education *

Some High School

High School Diploma or GED

Associates Degree

Bachelors Degree or higher

EMPLOYMENT HISTORY:

Current Or Last Position:

Employer:

Position Title:

Supervisor:

Start Date

MM / DD / YYYY

End Date

MM / DD / YYYY

Phone Number

### - ### - ####

Responsibilities:

Salary/Wage

Reason for Leaving

Resignation (with more than 1 week notice)

Resignation (with less than 1 week notice)

Laid-Off (lack of work)

Termination (performance concerns)

Acknowledgement

The above information is true and correct. I understand that, in the event of my employment by the Company, I shall be subject to dismissal if any information that I have given in this application is false or misleading or if I have failed to give any information herein requested, regardless of the time elapsed after discovery. I authorize the Company to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to the Company and will hold the Company and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information. I further authorize the Company to obtain any credit and consumer check. I understand that nothing in this employment application, the granting of an interview or my subsequent employment with the Company is intended to create an employment contract between myself and the Company under which my employment could be terminated only for cause. On the contrary I understand and agree that, if hired, my employment will be terminable at will and may be terminated by me or the Company at any time and for any reason. I understand that no person has any authority to enter into any agreement contrary to the foregoing. If employed, I will be required to provide original documents which verify my identity and right to work in the United States under the Immigration Reform and Control Act (IRCA) of 1986. The document(s) provided will be used for completion of Form I-9. Zumbro House, Inc. is an equal opportunity employer.

MINNESOTA DEPARTMENT OF HUMAN SERVICES LICENSED FACILITIES
EDUCATIONAL PROGRAMS, TEMPORARY EMPLOYMENT AGENCIES,
PROFESSIONAL SERVICES AGENCIES
BACKGROUND STUDY PRIVACY NOTICE

Because the Minnesota Department of Human Services is requesting that you provide private information about yourself, the Minnesota Government Data practices Act requires that you be informed of the following:

1. Purpose and intended use of the information:

Minnesota Statues, chapter 245C, requires the Minnesota Department of Humans Services (DHS) to conduct background studies on individuals providing direct contact services to people receiving services from facilities and agencies licensed by DHS. The background studies are to be completed according to the requirements in Minnesota Statues, chapter 245C. The information requested will be used to perform a background study of you that will include at least a review of criminal conviction records held by the Minnesota Bureau of Criminal Apprehension and records of substantiated maltreatment of vulnerable adults and children. DHS may also later require you to submit additional information and/or your fingerprints if necessary to complete your background study. For all individuals who are subject to background studies by DHS, the corrections system will report new criminal convictions for disqualifying crimes to DHS. County agencies and the Minnesota Department of Health report substantiated findings of maltreatment of minors and vulnerable adults to DHS.

2. Whether you may refuse or are legally required to provide the information:

Minnesota Statutes, chapter 245C, states that the individual who is the subject of a study must provide sufficient information to endure an accurate study.

3. Known consequences that may arise from supplying the information:

Individuals who have histories with the characteristics identified in Minnesota Statutes, chapter 245C, will be disqualified from positions allowing direct contact with persons receiving services. Health-related licensing boards will make a determination whether to impose disciplinary or corrective action on individuals regulated by health-related licensing boards who have been determined to be responsible for substantiated maltreatment. Individuals who do not have disqualifying characteristics will not be disqualified.

4. Known consequences that will arise from refusing to supply the requested information:

Only items identified as “optional” may be left blank. Refusals to provide the information necessary to endure an accurate and complete background study will result in your disqualification and an order to the agency or facility to remove you from any position allowing direct contact to persons receiving services.

5. Identification of other agencies or entities authorized to receive this information:

The information you provide will be shared with the Minnesota Bureau of Criminal Apprehension. If DHS has reasonable cause to believe that other agencies may have information pertinent to a disqualification, the information may also be shared with county attorneys, county sheriffs, courts, county agencies local policies, the Federal Bureau of Investigation, the Office of the Attorney General, agencies with criminal record information systems in other states and juvenile courts. Background study results may be shared with the Minnesota Department of Health, the Minnesota Department of Corrections, and the Office of the Attorney General, non-licensed personal care provider organizations and health-related licensing boards. If you have a disqualifying characteristic, the facility will be told only that you are disqualified and will not be told what caused your disqualification, unless you were disqualified by refusing to cooperate with the background study or for serious and/or recurring maltreatment of a minor or vulnerable adult. The information about you received as part of a background study is classified as private data and, except for the agencies noted, cannot be shared without your consent.

Please do not sign this box

Do you agree with the terms and conditions? *

Yes, I agree.

Date *

MM / DD / YYYY

By signing below, I am acknowledging that I have reviewed the above Minnesota Department of Human Services Background Study Notice and that $10.00 will be deducted from my first paycheck to pay for the state required background study.
I also affirm that all information contained herein this application is true and correct. Any falsification of information discovered after hire, will result in separation of employment. (use mouse to sign) *

Clear

ZUMBRO HOUSE INC. IS AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER. WE PROVIDE EQUAL OPPORTUNITIES TO ALL QUALIFIED EMPLOYEES AND APPLICANTS FOR EMPLOYMENT WITHOUT REGARD TO RACE, RELIGION, SEX, AGE, MARITAL STATUS, NATIONAL ORIGiN, SEXUAL ORIENTATION, CITIZENSHIP STATUS, VETERAN STATUS, DISABILITY, OR ANY OTHER LEGALLY PROTECTED STATUS. WE PROHIBIT DISCRIMINATION IN DECISIONS CONCERNING RECRUITMENT, HIRING, COMPENSATION, BENEFITS, TRAINING, TERMINATION, PROMOTIONS, OR ANY OTHER CONDITION OF EMPLOYMENT OR CAREER DEVELOPMENT

Please do not sign this box