Program Coordinator Application

Name*

First Middle Last

Address*

Street Address Apt City State Zip

Phone Number*

Email Address*

If hired, can you provide proof that you are legally authorized to work in the U.S.?*

Yes
No

Are you at least 18 years of age & do you have a valid Driver's License?*

Yes
No

Are you able to accept a position that requires use of your automobile with auto insurance?*

Yes
No

If under 18, are you able to accept a position that requires Driver's License?*

Yes
No

If under 18, are you able to accept a position that requires use of your automobile with auto insurance?*

Yes
No

Job Type:*

Do you have prior Group Home Experience?*

Yes
No

Do you have First Aid & CPR certificate?*

Yes
No

Do you have Med Admin certificate?*

Yes
No

Education

High School Name & Address:*

Last year completed

9
10
11
12

Course of study

College Name & Address:

Last year completed:

1
2
3
4

Major:

Degree:

Months attended:

Personal References

(Please list THREE employment/professional references and one personal character reference.)

Personal References 1

Name	Occupation	Address	Phone

Personal References 2

Name	Occupation	Address	Phone

Personal References 3

Name	Occupation	Address	Phone

Previous Employment

List employers starting with your present or most recent employer.

Previous Employment 1

Employer:	Dates Employed( from-to):	City:	State:	Phone:	Position held:	Supervisor:	Description of Duties:	Reason for leaving:	May we contact this employer?

Previous Employment 2

Employer:	Dates Employed( from-to):	City:	State:	Phone:	Position held:	Supervisor:	Description of Duties:	Reason for leaving:	May we contact this employer?

Other relevant experience, skills or qualifications:*

Do you have any physical condition, which may limit your ability to perform the job for which you are applying?*

Yes
No

If yes, describe the condition and explain how you can perform the job for which you are applying despite it.*

Gender:*

Male
Female

Check one of the following Race/Ethic Groups:*

Who referred you?*

Does this person work for Tolad Inc?*

Yes
No

Why do you want to work in this field?*

What added value would you be bringing to Tolad & its consumers?*

Upload Your Resume Here:

Drop files here or

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Please note: At any time during your employment, a physical, mental, health, chemical dependency, or criminal history evaluation may be required if there is reasonable cuase to believe the qualification requirements have not been met or that the employee cannot provide required care for the resident. Failure to comply with any of the following requirements will result in immediate separation from employment with this agency.

I hereby affirm that all statements are accurate, complete and true to the best of my knowledge. I understand that if knowingly give false information, I will not be eligible for employment with this agency.

In addition, I acknowledge that if hired, the employment relationship will be at will. “At will” employment means that the employer or employee may terminate the relationship at any time, with or without notice and for any reason or no reason. The “At Will” nature of employment can be changed only by a written agreement between the prospective employee and the authorized senior managerial employee.

Signature*

Print Name

Date*

Please review this list of qualifications. This listing is to be used to identify employee qualification standards for employment in positions that require contact with adults and children receiving services from Tolad, Inc. This is not a complete listing of all the qualification standards but rather a listing of those most critical. If an offer of employment is made to you, these qualification standards will be checked through the State Bureau of Criminal Apprehension, local District Court records, Department of Human Services, County Social Services Agencies and Local Police Departments. Any of these standards, as well as other employment requirements, may be a disqualification of these standards, as well as other employment requirements, may be a disqualification of these standards, as well as other employment requirements, may be a disqualification of these standards, as well other employment requirements, may be a disqualification for that employment requirements, may be a disqualification for that employment offer.

Willingness to disclose your arrest, conviction and criminal history.
Conviction of, or awaiting trial for or admission of any of the following crimes:
- Possession, use, sale, manufacture and or distribution of illegal drugs and simulated illegal drugs (M.S. sections 152.09, 152.096, 152.097).
- Murder, manslaughter, aiding a person in a suicide or attempted suicide (M.S. sections 609.185 to 609.215)
- Assault, harm caused by a dog, mistreatment of persons confined, mistreatment of residents or patients, use of drugs to injure or facilitate crime, robbery, kidnapping, false imprisonment, depriving another of custodial or parental rights or abduction (M.M. section 609.221 to 609.265).
- Incest, malicious punishment of a child or neglect of a child (M.S. section 609.365, 609.377 to 609.378).
- Theft, possession of shoplifting gear bringing stolen goods into the state, receiving stolen property, embezzlement of public funds, or rustling and livestock theft (M.S. sections 609.52, 609.521, 609.525, 609.53, 609.54, 609.551, 609.821).
- Arson, burglary, or possession of burglary tools (M.S. sections 609.561 to 609.563, 609.582 and 609.59).
Subject of an investigation for or admission to abusing or neglecting an adult or child (M.S. section 260.221, paragraph (b).
Involuntary termination of your parental rights within the past five years (M.S. section 260.221, paragraph (b).
Diagnosis of mental illness or mental condition.
Abuse of prescription drugs.
Use of controlled substances (M.S. Chapter 152).
Abuse of alcohol.

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job related medical condition handicap, or any other legally protected status.

I Understand That I Need To Schedule My Interview Time On The Next Page*

Yes I Do

I Understand That This Interview Will Be IN PERSON & FACE TO FACE*

Yes I Do

Please Fill Out The Application Below.

Education

Personal References

Previous Employment