Form Page: LBSA_Job_Application

EMPLOYMENT APPLICATION FORM

AN EQUAL OPPORTUNITY EMPLOYER
Employees of Laura Baker Services Association (LBSA) are treated during the hiring process and employment without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, or any other legally protected status.

PART I: PERSONAL INFORMATION

What Position if Other Selected?

Position Applying for:

Full Name:

Address:

Zip Code:

State:

City:

Cell Phone:

Work Phone:

Home Phone:

Email:

Date Available to Start:

Desired Salary:

Hours Available to Work:

Referred by:

I have previously applied to Laura Baker Services & Association.

I am presently employed.

How do you prefer to be contacted?

PART II: EDUCATION

Do you have a High School Diploma or your GED?

High School Name & Location:

College Name & Location:

Number of Years Attended:

Degree Earned/Majors or Subjects Studied:

Other Educational Institution & Location:

Number of Years Attended:

Degree Earned/Majors or Subjects Studied:

Other Specialized Training, Education, or Research Work:

Minnesota Licenses or Certifications:

PART III: EMPLOYMENT

Employer:

End Date:

Start Date:

Status:

Position:

Employer:

Status:

End Date:

Start Date:

Position:

Employer:

Start Date:

Status:

End Date:

Position:

PART IV: REFERENCES

Name three persons who are not related to you whom you have known for at least one year and who are acquainted with your professional abilities. If you are registered with a placement office, please ask them to forward your credentials.

Name:

Phone#:

Address:

Years Aquainted:

Phone#:

Name:

Address:

Years Aquainted:

Phone#:

Name:

Address:

Years Aquainted:

PART V: QUESTION

Please answer the question below in a complete and concise manner.

What do you see as the "special" needs of individuals who are developmentally disabled?

UPLOAD YOUR RESUME

Must be in .doc, .txt, or .pdf format.

Resume

AFFIDAVIT
I certify that the answers given by me on this application are true and correct without consequential omissions of any kind whatsoever. I agree that Laura Baker Services Association shall not be liable in any respect if my employment is terminated because of the falsity of statements, answers, or omissions made by me on this application. I authorize the companies, schools, or persons named above to give any information regarding my employment, my physical condition, together with any information they may have regarding me whether or not it is in their records. I hereby release said companies, schools, or persons from all liability for any damage for issuing this information. In addition, I hereby agree to abide by the rules and policies of LBSA and accept the established pay-periods as provided in accordance with the Fair Labor Standards Act (as amended). Upon my termination, I authorize the release of information on my work at Laura Baker Services Association.

Yes

By checking this box agree with the above AFFIDAVIT & checking the box is equivalent to my signature.

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