2.0.5.0.06

COMMUNITY OPTIONS & RESOURCES
330 1/2 Fox Lake Ave, PO Box 333, Sherburn, MN 56171
(507) 764-4612
www.cormn.com
APPLICATION FOR EMPLOYMENT

This organization does not discriminate in hiring or employment on the basis of race, color, religion, creed, national origin, sex, sexual orientation, marital status, familial status, membership or activity in a local human rights commission, status with regard to public assistance, age, or disability unrelated to the ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination. This application will be given every consideration, however, its receipt does not imply that the applicant will be interviewed or employed. COR is an E-Verify and Right to Work participant. EEO / AA

Personal Information

 
 
 Last  First  Maiden / Previous  E-Mail Address    
 
 Street City  State  ZIP Code  Telephone Number  
Are you legally able to work in the US? 
If no, explain:
EDUCATION
  Name of School Location (City, State)
Grammar or Grade School
High School
College
Vocational or Business
Other
PROFESSIONAL LICENSES AND/OR CERTIFICATIONS
 Type:
 Organization or State Issued:
 Date Issued:
 Number

 Type:
 Organization or State Issued:
 Date Issued:
 Number
EMPLOYMENT RECORD (List last or present position first)
Present and Former Employers Dates Employed Salary Range Reason for Leaving    
 Name:  From:  Starting:
 City/State:  To:  Ending:
 Supervisor's
 Name:
 
 Telephone Number:  

 Name:  From:  Starting:
 City/State:  To:  Ending:
 Supervisor's
 Name:
 
 Telephone Number:  

 Name:  From:  Starting:
 City/State:  To:  Ending:
 Supervisor's
 Name:
 
 Telephone Number:  

 Name:  From:  Starting:
 City/State:  To:  Ending:
 Supervisor's
 Name:
 
 Telephone Number:  
 
 Are You Employed Now?
May We Contact Your Present Employer?
 
      If No, Why:
 Please explain all periods of unemployment:
 
 
An approved background study is required for employment (a conviction itself does not constitute an automatic bar to employment, the seriousness of the crime and date of the conviction will be considered).

Please list at least 3 people not related to you, whom you have known at least five years, that we may contact for personal references.

       
  Name City/State Phone Number
Reference #1
Reference #2
Reference #3
       
AVAILABILITY RECORD

 Date available:  

 Please go to our website, www.cormn.com, and see the available hours. What position opening(s)/site/town are you interested in?

 
1st Choice: 2nd Choice:
 
Are you interested in:  Full Time: Yes No Part Time: Yes No Fill-in: Yes No  
 
Wage range to          
Are you available to work:  
 
 
 
 
 
  Weekends? Yes No Holidays? Yes No  
  Awake Overnights?
Sleep Overnights
 
 
 Our services are twenty-four hours a day/seven days a week. Please state what hours you are not available to work.  
 
APPLICATION QUESTIONNAIRE:
Have you ever been employed by Community Options & Resources (formerly Friendship Haven)?
 
What qualifications, education, skills or experience do you have for this position?
Do you have access to dependable transportation to get to and from work?
 
This position may require transporting people and a need to drive a COR vehicle. Do you have a valid driver's license?
 
How did you hear about employment at COR? Please specify(names, newspapers, etc.)

To the applicant: The list below describes some of the activities/duties that may be required in the position applied for.

If hired, you would be specifically trained prior to assuming responsibility.

Please indicate your ability and willingness to do the following:
 
Please indicate your ability and willingness to do the following:
1. Advocating for people and their rights
2. Offering choices to people
3. Communicating with people who have difficulty understanding or speaking
4. Supporting/accompanying people: where they want to go
5.   on medical appointments
6.   on trips to larger cities
7. Supporting people and participating in swimming activities
8. Supporting people and participating in community activities (bowling, Special Olympics)
9. Support people and participating in physical activities (walks, bike rides, etc.)
10. Attending church and related activities with people.
11. Supporting / assisting people with: bathing/showering
12.   grooming
13.   toileting
14.   dressing
15.   eating
16.   behavior management
17.   laundry
18.   cleaning
19.   cooking and meal preparation
20. Use of and supporting people with their use of adaptive equipment (walkers, canes, wheelchairs, power lifts, etc.)
21. Lifting and transferring people
22. Passing medication and performing medical treatments after training.
23. Exposure to bodily fluids (vomit, BM, urine, blood, etc)
24. Using your own vehicle to transport people if needed and approved
25. Driving at night
26. Filling in for a co-worker
27. Coming to work early if needed/when requested
28. Coming to work on short notice
29. Completing trainings assigned by COR
30. Completing basic computer skills
 
 
I voluntarily give COR the right to thoroughly investigate my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies, or corporations supplying such information.

I understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.


MY TYPED NAME BELOW SHALL HAVE THE SAME FORCE AND EFFECT AS MY WRITTEN SIGNATURE.

Applicant Name    Today's Date: