Flash: ON   November 23, 2017 
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7400 Laurel Ave.
Golden Valley, MN  55426
Phone: 763 541-1844
Fax: 763 541-0415
Contact Via Email


Application for Employment

Name*
Street Address*
City*
State*
Zip Code*
Telephone Number*
Cell Phone Number
E-Mail Address
Do you Have a High School Diploma/GED?*
 Yes
 No
Do You have a Bachelor's Degree?
 Yes
 No
List All Post-High School Education Completed. Include Dates Attended, Degree and Major.
Direct Service positions at WorkAbilities, Inc. involve rigorous physical activities which may include the physical ability to 1) stand and walk for up to seven hours a day 2) perform two-person lifts of adult clients throughout the day, including squatting, pivoting, flexing and kneeling; 3) independently roll, position or complete ROM/Stretching exercises with clients 4) push clients in wheelchairs on both level and incline surfaces 5) engage in repetitive lifting or other physical movements in care of clients or in fulfilling production demands. Are you able with or without reasonable accommodation, able to perform all of these job functions?*
 Yes
 No
Employment Offer is contingent on the employee demonstrating the safe ability to perform essential tasks on a Physical Abilities Test.

Do you understand and agree that you will be required to take the Physical Abilities Test and that employment is contingent on demonstrating the safe ability to perform essential tasks? *
 Yes
 No
Current or Most Recent Employer
Address
Telephone Number*
Job Title
Date Started:
Date Ended:
Job Responsibilities
Reason for Leaving
Employer
Address
Telephone
Job Title
Date Started:
Date Ended:
Job Responsibilities
Reason for Leaving
Do you have a valid Minnesota Driver's License*
 Yes
 No
Driver License Number
Are you Legally Eligible for Employment in the U.S.? *Proof of U.S. Citizenship immigration status will be required upon employment.*
 Yes
 No
Please Read: WorkAbilities, Inc. is an equal opportunity employer. WorkAbilities, Inc. does not discriminate in employment, and no question on this application is used for the purpose of limiting or excluding any applicant's consideration for employment on a basis prohibited by local, state, or federal law. I give WorkAbilities, Inc. the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability WorkAbilities, Inc. and its representatives for seeking such information and all other persons, corporations, or organizations from furnishing such information. It is understood and agreed that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from WorkAbilities, Inc.'s services if I have been employed. I also understand that employment is contingent on successful completion of a background study and clearance from the Department of Human Services. Furthermore, I understand that just as I am free to resign at any time, WorkAbilities Inc. reserves the right to terminate my employment at any time, with or without cause, and without prior notice. I understand that no representative of WorkAbilities, Inc. has the authority to make any assurances to the contrary. Include your name below to acknowledge that you understand and agree to these terms. *
Date of Signature*
Referral Source:
Additional Education, Training or Experience you would like to add:


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