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EastHaven Halfway HouseShelter From the Storm

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EastHaven Halfway House

1425 East St. Germain St. Cloud, MN 56304

Personal

First Name

Last Name

Address

Address 2

City

State

Zip

Email address

Phone Number

Position Applied For

Salary Expectations

Date Available

Employment Experience

Please list your previous three employers with your most recent employment first.

Employer

Phone

Address

Start Date

End Date

Title

Description of Responsibilities

Salary

Reason for Leaving:

Can we contact this employer:
YesNo

Employer

Phone

Address

Start Date

End Date

Title

Description of Responsibilities

Salary

Reason for Leaving:

Can we contact this employer:
YesNo

Employer

Phone

Address

Start Date

End Date

Title

Description of Responsibilities

Salary

Reason for Leaving:

Can we contact this employer:
YesNo

Education

First Name

Years Attended

Area of Study

Degree Received

Phone

Address

First Name

Years Attended

Area of Study

Degree Received

Phone

Address

First Name

Years Attended

Area of Study

Degree Received

Phone

Address

Special Skills Training

Please list any special skills training, such as First Aid, CPR, Crisis Intervention, etc. Licensure Status (if applicable)

References

Please list three references: Two professional & One Personal. The Haven will contact
previous employers to verify employment, dates of hire and question of re-hire.

Name

Title

Organization

Address

Relationship

Phone

Please list three references: Two professional & One Personal. The Haven will contact
previous employers to verify employment, dates of hire and question of re-hire.

Name

Title

Organization

Address

Relationship

Phone

Please list three references: Two professional & One Personal. The Haven will contact
previous employers to verify employment, dates of hire and question of re-hire.

Name

Title

Organization

Address

Relationship

Phone

Questions

Please explain any “Yes” answers. Attach a separate sheet if needed. By answering “Yes”
– you will not automatically be rejected for employment. Each situation is reviewed on a
case by case basis.

Have you been convicted of a felony within the past seven (7) years?

Have you ever been arrested for assault, theft or crimes against others?

Have you ever been terminated or asked to resign from a position?

Have there been any ethical complaints as a result of your work?

Have you had lawsuits as a result of your professional position?

Have you been accused of sexual harassment by co-workers in any setting?

I, the undersigned, hereby declare that all information provided above is true and complete, and permit The Haven to contact the previously listed sources to release and verify applicant information.
Attach any documents you need

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