Employment Application
Tri-Valley is an Affirmative Action / Equal Opportunity Employer

Administrative Office: 102 North Broadway; Crookston, MN 56716
Phone: 800.584.7020 or 218.281.5832 or 711
for Relay Telecommunication Service.
This form is available in alternative formats upon request
"NERF ID"
Please complete all sections as requested, even if submitting a resume. Your employment application must show how you meet the minimum requirements of the position to be considered.

Personal Information
First Name (Legal Name):
MI:
Last Name (Legal Name):
Former Name(s) used:
Current  Street Address
Current Mailing Address (if different than above):
Current City:
State:
Zip:
Email Address:
Verify Email Address:
  
Home Phone:
Cell Phone:
Additional Contact Information (optional):
Name:
Phone:
Cell:

Additional Information
Desired Positions(s):
Desired Locations(s):
Do you want to work:
Full-time Part-time Temp Substitute Seasonal Head Start
Hours/Days available:
How did you hear about this position?
Advertisement
Walk-in
Friend/Relative
Internal Posting
Tri-Valley Employee
Website
Employment Agency/Job Service
Other,
Date available for work:
Are you under 18? Yes No
Have you ever been employed by Tri-Valley before? Yes No
 
 
If yes: Last year worked?
Location?
Reason for leaving?
If required for position, do you have a current driver's license?
Yes No
Current vehicle insurance?
Yes No
Are you currently or have you been a Head Start Parent? Current Past No

 
  Employment History
Please list current and two previous employers, assignments, internships, or volunteer activities, starting with the most recent employer.
Current Employer:
Job Title:
Company Address
City
State
Zip
Direct Supervisor Name:
Supervisor Title:
Phone Number:
Start Date:
Starting Rate of Pay:
$
Current Rate of Pay:
$
OK to contact?  Yes No
Responsibilities and Duties Explanation:
Why are you seeking other employment opportunities?
Past Employer:
Job Title:
Company Address
City
State
Zip
Direct Supervisor:
Supervisor Title:
Phone Number:
Start Date:
End Date:
Starting Rate of Pay:
$
Ending Rate of Pay:
$
OK to Contact? Yes No
Responsibilities and Duties Explanation:
Reason for Leaving:
Past Employer
Job Title:
Company Address
City
State
Zip
Direct Supervisor:
Supervisor Title:
Phone Number:
Start Date:
End Date:
Starting Rate of Pay:
$
Ending Rate of Pay:
$
OK to Contact? Yes No
Responsibilities and Duties Explanation:
Reason for Leaving:
Other:
Additional experience relative to position applying for:
Please explain gaps in employment:

REQUIRED FOR HEAD START TEACHER, ASSISTANT TEACHER, CLASSROOM ADVOCATE POSITIONS:
Please list hours/experience below and attach a copy of your degree, transcript, or CDA as required for position applying for to determine qualifications. You cannot be considered for employment without this information.
Hours/Experience working with infants:
Hours/Experience working with toddlers:
Hours/Experience working with preschool:

EDUCATION:
Please attach copies of diploma/license/certification - as required by this position
 
Name & Address
Related Classes/ Major
Years completed
Degree/ Diploma Earned
High
School
College
 
Other
 

Communication Skills:
Check all that apply:
Language:
Please describe your skills for the selected languages
English 
Spanish
Somali
Sign-Language
Other, list:
Please share your experiences with the populations served by Tri-Valley Programs, i.e.: Migrant Children & Families, Low Income Children & Families, Seniors, and the general public.



Training and Skills Summary:
Summarize applicable trainings, certifications, licenses, and skills that you feel help qualify you for position:

REFERENCES:
References (do not include friends or relatives) May include professional contacts, co-workers, teachers, church, school, community members:
1.  Name of Reference:
Phone number:
Cell/Work number:
Email Address:
Relationship:
Years Known:
2.  Name of Reference:
Phone number:
Cell/Work number:
Email Address:
Relationship:
Years Known:
3.  Name of Reference:
Phone number:
Cell/Work number:
Email Address:
Relationship:
Years Known:

APPLICANT CERTIFICATION:

Please read this statement carefully before signing this application.
 
I understand Tri-Valley Opportunity Council, Inc. is an "at-will employer" and if I am hired, my employment may be terminated at the will of either party, with or without cause, and without prior notice.
 
Tri-Valley Opportunity Council, Inc. is an Affirmative Action, Equal Opportunity Employer. Qualified applicants are considered without regard to race, creed, color, national origin, age, religion, sex, marital status, status with regard to public assistance, disability, sexual orientation, veteran status, genetic information, gender identity, familial status, membership or activity in a local human rights commission, or any other legally protected status under local, state, or federal laws.
 
I authorize Tri-Valley Opportunity Council, Inc. to verify information provided on this application, of which I certify is accurate to the best of my knowledge. I understand that I am not required to provide requested information, however if I do not, I may not be considered for employment with Tri-Valley Opportunity Council, Inc. I also understand that providing false information may be cause for rejection of my application and consideration for employment or cause for dismissal from employment.
 
I understand that if I am selected for employement, based on position requirements, I may be required to submit to and pass a pre-employment drug screening, criminal, sex offender and program specific background searches as a condition of employment.
 
Signature:
I have read and understand the above certification statement. I have reviewed the job description for the position applying for and certify that I am able to perform the essential functions listed, with or without a reasonable accommodation. Please accept my application for employment with Tri-Valley Opportunity Council, Inc.
Note: By typing your full name and the last 4 digits of your Social Security Number, you are electronically signing this document.  
Full Name:
Last 4 digits of SS#:
Date:
Please attach copies of required degrees, certifications, or licenses and ensure your application shows any required work experiences. This is necessary for the hiring supervisor to determine if you meet minimum requirements of the position in order to proceed with consideration.





OFFICE USE ONLY: Federal Reporting
NERF ID # :
Title:
Category:
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