Application for Employment – Vision Loss Resources

Employment Application

Name(Required)

First Middle Last

Date

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email

Desired Position(Required)

Referred by

Desired Salary

Are you applying for:(Required)

Full-Time
Part-Time
Temporary
Seasonal

Can you perform the essential functions of the position you are applying for?(Required)

Yes
No

Under federal law, we may hire only persons authorized to work in the U.S. As a condition of employment, I understand that I will be required to furnish proof of my idenity and authorized to work in the U.S. as required by law. Are you legally authorized to work in the United States?(Required)

Yes
No

Will you now or in the future require sponsorship for the employment visa status? (e.g., H-1B visa status)(Required)

Yes
No

Are you employed now?

Yes
No

How many hours a week would you like to work?

If hired, when can you begin work?

Do you have a valid driver's license?(Required)

Yes
No

State you are licensed:

Drivers License Number

Language Skills speak, read, write or sign:

Other Skills: list special skills and qualifications:

Education

Please list Education level, name and location of school, years completed and degree awarded.

Education(Required)

Employment Record

Please give accurate, complete full-time and part-time employment history starting with your present or most recent employer. If attaching resume, you must still complete all sections.

Company Name

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Hire

Last day of employment

If current employed leave blank

What was your job title?

Reason for Leaving:

Company Name

Phone

Starting Pay

Ending Pay

References

List three professional references was may contact (e.g., current or former managers, peers, customers, etc.).

Name

First Last

Company

Title

Relationship

Phone

Name

First Last

Company

Title

Relationship

Phone

Name

First Last

Company

Title

Relationship

Phone

Please Read and Certify the Following

Vision Loss Resources (VLR), DeafBlind Services Minneapolis (DBSM) and Contract Production Services (CPS) are Equal Opportunity Employers. Prospective employees will receive consideration without discrimination because of race, color, creed, religion, national origin, sex, marital status, status with regard to public assistance, membership or active in local commission, disability, sexual orientation, genetic testing information, age or any other characteristic by state or federal law. - I certify that the statements that I have made in this application are true and complete and that I have read, understand, and agree to all the provision contained in this application or violation of any of the provisions contained herein may be cause for disqualification or immediate dismissal. -In consideration of my employment, I agree to conform to the policies an procedures of VLR, DBSM, and CPS. I understand that in accepting this application, the organization is in no way obligated to provide me with employment and that I am not obligated to accept employment if offered. Furthermore, if employed with VLR, DBSM, and CPS, I understand that I am employed "at-will" and that my employment and compensation can be terminated with or without cause, and with or without notice at any time, at either the opinion or the organization or myself. I further understand that no supervision, manager, or representative of the Company has authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, except in writing when authorized by the CEO of VLR, DBSM, and CPS. -I authorize VLR, DBSM, and CPS to investigate all statements contained herein and to use the information contained in this application form or in my personnel file; (1) to contact my previous employers about my qualification for the job applied for (2) to answer job related inquiries from possible future employers, (3)to contact schools for pertinent information, and (4)to contact the references listed above. I understand that this application form will be considered active for six (6) months from the date it is signed and dated by me. -I understand that if I am offered employment the organization may require and perform a criminal background check and I may be subject to drug testing.

Consent

I agree to the privacy policy.

Cover Letter

Max. file size: 128 MB.

Resume

Max. file size: 128 MB.

Phone

This field is for validation purposes and should be left unchanged.