Harry Meyering Center, Inc.
We make a difference in people's lives.

Employment Application

Personal Information

Harry Meyering Center, Inc. is an Equal Opportunity / Affirmative Action Employer
Employees and applicants for employment are provided equal opportunity without regard to race, color, creed, religion, national origin, ancestry, sex, marital status, age, disability, sexual orientation, veteran’s status, status with regard to public assistance, or any other protected class.

For information regarding employment opportunities contact
Human Resources Director
109 Homestead Rd
Mankato, MN 56001
(507) 388-8972
ballen@harrymeyeringcenter.org
www.harrymeyeringcenter.org

Incomplete applications will not be accepted. Application is active for 30 days from date received.

Name:
Current Address:
City:	State:	Zip:
Telephone:	Cell Phone:	E-mail:

Permanent Address (if different from above):
City:	State:	Zip:

Social Security number: - -
How did you become aware of an opening?
Have you ever worked for HMC? Yes No
If yes, which location and when?

Position Desired:
Are you looking for: Full-time Part-time Regular Seasonal
Rate of pay expected:

Most positions require working weekends and holidays. Are you willing to do so? Yes No
If you are a student, how many hours are you willing to work?

Check days available:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Do you have a legal right to work in the U.S.? Yes No
*Verification of employment eligibility is required at the time of a conditional job offer.*

Education Information

High School:
Address:
City:	State:	Zip:
Did you graduate?: Yes No

Post High School:
Address:
City:	State:	Zip:
Degree, Certification or Major Area of Study:

Current/Previous Employment

HMC reserves the right to contact former employers

Employer:		Telephone:
Address:		Fax:
City:	State:	Zip:
Dates of employment: from: to:
Hourly Rate/Salary:
Position Held:
Name, Title, and Phone Number of Immediate Supervisor:
Reason for leaving:
Summarize the nature of the work performed and job responsibilities:

Employer:		Telephone:
Address:		Fax:
City:	State:	Zip:
Dates of employment: from: to:
Hourly Rate/Salary:
Position Held:
Name, Title, and Phone Number of Immediate Supervisor:
Reason for leaving:
Summarize the nature of the work performed and job responsibilities:

Employer:		Telephone:
Address:		Fax:
City:	State:	Zip:
Dates of employment: from: to:
Hourly Rate/Salary:
Position Held:
Name, Title, and Phone Number of Immediate Supervisor:
Reason for leaving:
Summarize the nature of the work performed and job responsibilities:

Of your former jobs, are there any you feel have given you experience or training that would be beneficial to the position you are seeking at Harry Meyering Center?

Are you currently certified in:
First Aid
CPR
Lifesaving
Medication Administration

References

Please list one additional work related reference and one personal reference.

Name:		Phone:
Address:		Years Known:
City:	State:	Zip:
Occupation:		Personal Reference Work-Related Reference

Name:		Phone:
Address:		Years Known:
City:	State:	Zip:
Occupation:		Personal Reference Work-Related Reference

Read the following section thoroughly and answer the questions.

As part of directly supporting persons served by Harry Meyering Center, you may be required to physically intervene in an incident where a person may become aggressive. This may mean assisting to carry someone out of an area, holding someone, blocking a hit, dodging a kick or holding a person’s arms at his/her side. You may be assigned to a home where lifting persons is required. You would be part of a two-person lift and expected to lift up to 60 pounds.

Most positions require an employee to drive. Do you have a current drivers license?
Yes No

Have you ever been convicted of a crime (gross misdemeanor or felony) or have you ever pleaded no contest in connection with any charges related to a gross misdemeanor or felony?
Yes No
YOUR CONVICTION OR PLEADING OF NO CONTEST IS NOT AN ABSOLUTE BAR TO EMPLOYMENT. MN Law mandates that employees cannot have been convicted of or found to be in violation of numerous statutes. If the Harry Meyering Center makes a conditional offer of employment to you, the Minnesota Department of Human Services will do a criminal background check on you. This conditional offer of employment may be withdrawn or, if you have commenced work, your employment may be terminated if the Harry Meyering Center, Inc. is dissatisfied, in any way, with the results of information obtained through the background check.

Harry Meyering Center is committed to maintaining a work environment that is free from the influence of illegal drugs and alcohol to protect the health, safety and well-being of our employees and the people we serve. If Harry Meyering Center makes a conditional offer of employment to you, you will be required to undergo a drug test. If the initial and confirmatory drug tests are positive and there is no satisfactory explanation of the positive results, the offer of employment will be revoked.

(a) I hereby authorize the investigation of all statements contained in this application. I agree that if I make any misrepresentations regarding the information in this application, or if I fail to disclose information requested, or if any investigation of my application is unsatisfactory for any reason, any offer of employment made to me by Harry Meyering Center, Inc. may be terminated immediately regardless of whenever the misrepresentations or omission is discovered. In this connection, if my employment is terminated, Harry Meyering Center, Inc. will have no obligation to me except to pay me, at the rate agreed upon, for work that I have actually performed up to the date of my termination. This application and any other documents presented to me in the course of applying for a position with Harry Meyering Center, Inc., are not contracts or promises of employment. I also understand that if I am hired, I will be an employee at will, which means that I have the right to terminate my employment at any time for any reason or no reason and that Harry Meyering Center, Inc. has the same right regarding discontinuation of my employment. I understand that any oral or written statements to the contrary are not binding on Harry Meyering Center, Inc., and that I may not rely upon them. (b) I authorize Harry Meyering Center, Inc. to investigate all statements on this application including work references. I authorize my previous employers, education-related references or other references to provide Harry Meyering Center, Inc. with all documents and information that it requests in conjunction with my application for employment. (c) As noted above, I acknowledge that any offer of employment is contingent upon successful completion of a criminal background check and drug test. Further, I agree to any and all pre-placement health assessments including a physical examination as may be deemed necessary by Harry Meyering Center, Inc. and, further, understand that my employment is conditional upon my successful completion of the pre-employment health assessment and/or physical assessment. (d) Finally, I understand that Harry Meyering Center, Inc. reserves the right to interpret any and all of its policies, procedures, and handbooks and that its interpretation shall be final and binding on me.

Affirmative Action Voluntary Survey

Completion of information below is voluntary and will not affect any employment decision.

Harry Meyering Center, Inc.

Employees and applicants for employment are provided equal opportunity without regard to race, color, creed, religion, national origin, ancestry, sex, marital status, age, disability, sexual orientation, veteran’s status, status with regard to public assistance, or any other protected class.

We are an equal opportunity, affirmative action employer and we comply with government regulations and affirmative action reporting. In an effort to comply with requirements regarding government recordkeeping, reporting and other legal obligations, we request that you complete this Affirmative Action Survey. Providing this information is completely voluntary and refusal to provide information will not subject you to any adverse personnel decision/action or hiring decision. This survey is considered confidential information, is not part of your official application and is kept separate from your personnel file.

Gender:
Male Female

Ethnic/Race
Caucasian (white)
Hispanic or Latino
Native Hawaiian or other Pacific Islander
Black or African American
American Indian/Alaska Native
Asian
Multi-racial (two or more races)

Veteran Status
Non Veteran
Vietnam Era Veteran
Other Eligible Veteran
Recently Separated Veteran

Are you an individual with disabilities?:
Yes No

Harry Meyering Center, Inc. is an Equal Opportunity Affirmative Action Employer

Please re-read your application before submitting it!

BY CHECKING THIS BOX I HEREBY ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE STATEMENTS SET FORTH ABOVE.

______________________________________________________



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	Harry Meyering Center, Inc.
	Business office location: 109 Homestead Road, Mankato, MN 56001
	Contact webmaster at ballen@harrymeyeringcenter.org
	Last updated: 07/07/2008

Harry Meyering Center, Inc. We make a difference in people's lives.