Online Application

3737 Bryant Avenue South · Minneapolis, Minnesota 55409
Phone: (612) 827-5931 · (800) 735-3048

General Information
Name    
Current Address     

()-
Permanent Address
(if different than above)		      

()-
Social Security --
  Are you at least 18 years of age? Yes No
  Applicants between the ages of 14 and 18 will need to obtain parental permission for
  mandatory mantoux testing and emergency medical treatment.

  Can you legally work in the U.S.? Yes No
  Employment is subject to verification that you are of minimum legal age and
  can work legally in the U.S.
  Have you ever been convicted of any crime other than a minor misdemeanor? Yes No
  If yes, please explain. Answering "yes" will not automatically disqualify you for employment.

  
Position(s) Desired  

Full Time Part Time On Call hours per week Temporary:
Shift(s) Desired
Days Available Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Date Available Immediately Upon weeks notice Other
Have you ever worked for Walker before? Yes No
If yes, list when, which company/department and supervisor.


Do you have any friends/acquaintances working for Walker? (Answering "yes" will not automatically
disqualify you for employment) Yes No
Referred by   If newspaper ad, which paper?

Education
School
Name/Address of School
Course of Study
Level Completed
Did you graduate?
Diploma or Degree

High School




Yes 
No
If no, do you
have a G.E.D.?
 Yes No

Diploma Program




Yes 
No

College




Yes  
No

Graduate School




Yes 
No

Other Pertinent
Education






Yes  
No

Nursing Applicants Only
RN:


LPN:


TMA:


HHA
CNA:

Length of course
30   84   Other

Are you on the registry?
Yes No
If yes, which state/s?
Clerical Applicants Only

List office skills (typing, shorthand,
business machines, dictaphone, WP/Software)

Employment History
List complete employment history. Begin with most recent position; include military experience which may relate to the position
you are applying for; include all positions, regardless of their relation to the position for which you are applying; include dates for
employment for the past five years only.
Employer, Supervisor,
and Job Title
Address and Phone
Employment
Dates
Job Duties











From
  
To
  
Reason for leaving
Salary per Hour:    Full Time Part Time On Call Temp
May we contact your present employer for reference/verification purposes? Yes No











From
  
To
  
Reason for leaving
Salary per Hour:    Full Time Part Time On Call Temp
May we contact your present employer for reference/verification purposes? Yes No









From
  
To
  
Reason for leaving
Salary per Hour:    Full Time Part Time On Call Temp
May we contact your present employer for reference/verification purposes? Yes No










From
  
To
  

Reason for leaving
Salary per Hour:    Full Time Part Time On Call Temp
May we contact your present employer for reference/verification purposes? Yes No

Other Information
List volunteer and unpaid work experience which may relate to the position for which you are applying.
Do not include religious, ethnic or political group affirmation.
Volunteer Activity
Dates
Job Duties

From
  
To
  
If experience gained was more than five years ago, list only duration of experience  

REQUIRED–Read before continuing
I understand and agree that any offer of employment is conditional upon completing and passing a medical screening based on the physical demands of the job for which I am applying, acceptable reference checks, criminal background check, and successful completion of the orientation period.

I authorize investigation of all statements contained in this application and I understand that misinformation given on my employment application form and during the medical screening is sufficient cause for discharge, if I am employed.

I understand that nothing contained in this employment application or in the granting of an interview or in any policies, procedures, or handbooks that I might receive, is intended to create and employment contract between Walker and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon Walker. If an employment relationship is established, I understand that I have the right to terminate my employment at any time, for any reason, and Walker retains a similar right regarding the termination of my employment.
By checking this box, I acknowledge that I have read and understand the above conditions.

Date      


Equal Employment Opportunity Voluntary Disclosure (not required)
Applicants are considered for current open positions and employees are treated during employment without regard to race, color, religion, gender, national origin, age, marital status, veteran status, sexual or affectional orientation, disability or any other legally protected status.

As an employer with an Affirmative Action Program, we comply with government regulations and affirmative action responsibilities.

Solely to help us comply with government record keeping, reporting and other legal requirements, please fill out this Voluntary Disclosure. We appreciate your cooperation.

This data is for periodic government reporting and will be kept in a confidential file separate from the Employment Application.
Your cooperation is voluntary. Inclusion or exclusion of any data will not affect any employment decision.

Optional
     

      
Affirmative Action Survey (not required)
Government agencies require periodic reports on gender, ethnicity, disability and veteran status of applications. This data is for analysis and affirmative action only. Submission of information about a disability is voluntary.
Sex: Male Female Date of Birth:      

Race: Caucasian American Indian/Alaskan Native African American Hispanic Asian/Pacific Islander

Check any of the following if applicable: Disabled (Note 1) Vietnam Era Veteran (Note 2) Disabled Veteran (Note 3)

Years of education completed: