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We consider applicants for all positions with out regard to race, color, religion, creed, gender, national origin, age, disability, marital status, veteran status, sexual orientation, or any other legally protected status. We are an Equal Opportunity Employer.

To ensure proper consideration, please fill in the information below as completely and accurately as possible.

4629 Airpark Blvd Duluth, MN 55811 218-722-5009 info@trilliumservice.com

Personal Information

First Name *

Middle Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip Code *

Phone *

Email Address *

Type of Employment *

Full Time	Part Time
Either (FT or PT)	Internship

Position Applying For: *

Job Coach	Management
Employment Coordinator

How did you hear about us? (Check All that Apply) *

Have you been employed with Trillium previously? *

Yes	No
If yes, When? If yes, When?

Are you related to anyone receiving services from Trillium? *

Yes	No
If Yes, Who? If Yes, Who?

Are you legally authorized to work in the United States? *

Yes

No

Are you currently employed? *

Yes

No

If currently employed, may we contact your employer? *

Yes

No

Do you have a valid driver's license? *

Yes

No

Do you have use of an insured vehicle? *

Yes

No

Availability

Date Available to start? * +

Shift preference: *

Days Available *

Employment History

Employer 1

Company Name

Supervisor/Manager

Phone

City and State

Start Date +

End Date +

Position

Reason for Leaving

May we contact? *

Yes

No

Employer 2

Company Name

Supervisor/Manager

Phone

City and State

Start Date +

End Date +

Position

Reason for Leaving

May we contact? *

Yes

No

Employer 3

Company Name

Supervisor/Manager

Phone

City and State

Start Date +

End Date +

Position

Reason for Leaving

May we contact? *

Yes

No

Education

High School Name/Location or GED *

Last Year Completed *

9th	10th
11th	12th

Did you Graduate: *

Yes

No

College Name/Location

Field of Study

Last Year Completed

Did you Graduate:

Yes

No

Other (Specify)

Field of Study

Last Year Completed

1st	2nd
3rd	4th

Did you Graduate:

Yes

No

References

Professional Reference 1

Name *

Employer/Title *

Email Address

Phone *

Professional Reference 2

Name *

Employer/Title *

Email Address

Phone *

Personal Reference 3

Name *

Employer/Title *

Email Address

Phone *

Authorization to Check References

I consent to and authorize Trillium Services, Inc. and its employees to obtain any reference information concerning me, including achievement, wage history, performance, attendance, personal history, disciplinary information and reason for separation of employment, as it relates to my previous employment. It is expressly understood that any information sought or obtained is to be used for the sole purpose of my acceptability for employment. I also hereby release Trillium Services, Inc. and its employees from all liability for damages or claims resultant from any reference information sought or obtained pursuant to this authorization.

I also consent to and authorize the above named former employers, and its agents and employees, to furnish any reference information concerning me, including achievement, wage history, performance, attendance, personal history, disciplinary information and reason for separation of employment, as it relates to my previous employment. It is expressly understood that any information sought or obtained is to be used for the sole purpose of my acceptability for employment. I also hereby release the above named employers and its employees from all liability for damages or claims resultant from any reference information sought or obtained pursuant to this authorization.

Signature and Date: *

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Interests and Skills

At Trillium we try to match all of our applicants with the best person for them to work with. In order to make that match we are looking for a little bit of information from you about your hobbies and interests. Thank you in advance!

What are some of your hobbies? (Check as many as apply to you) *

Favorite Food? *

Favorite Music? *

Favorite Beverage? *

Favorite Hobby? *

Favorite Sports Team? *

Favorite TV Show/ Movie? *

Favorite Season? *

Favorite Book/Author? *

Favorite Indoor/Outdoor Activity? *

List memberships in professional, trade, business and or student organizations.

Other Qualifications: Summarize special job related skills, qualifications, workshops, and in-service training from employment or other experiences.

Specialized Skills: Check Skills (If Applicable) *

State any additional information that you feel may be helpful to us in considering your application for employment.

Trillium Services, Inc. is an At-Will Employer

I acknowledge the employment at Trillium Services, Inc. is on an "at-will" basis and is for no definite period of time. Employment that is on an "at-will" basis may be terminated at any time with or without notice and without cause. The Board of Directors have the authority to alter your "at-will" status. Any agreement altering your at-will employment status must be in writing and signed by the Chairman of the Board.

I verify that all information in my application is true and complete. I understand that false statements given on this application may be considered for refusal of or separation from my position. I authorize Trillium Services, Inc. to investigate all statement and information contained in this application which they may consider relevant to my employment.

Signature/Date: *

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Direct Care Qualification Standards

Please review this list of qualifications. This form is to be used by individuals, corporations, partnerships, or governmental units to screen individuals for licensed services (9555.6125). This is not a complete listing of all 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 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 for that employment offer. Please see complete list of disqualifications prior to submission https://www.revisor.mn.gov/statutes/?id=245C.15.

1. Willingness to disclose your arrest, conviction and criminal history.

2. Felony convictions under MN Statutes, Chapter 152 (prohibited drugs)

3. Conviction of, or awaiting trial for or admission of any of the following crimes:

Murder, manslaughter, aiding a person in a suicide or attempted suicide, criminal vehicular homicide or injury

Assault, great bodily harm caused by distribution of drugs, mistreatment of persons confined mistreatment of residents or patients, use of drugs to injure or facilitate crime, robbery, kidnapping, false imprisonment, abduction (M.S. sections 609.221 to 609.265)

Murder of an unborn child (not abortion), manslaughter of an unborn child, injury or death of an unborn child in the commission of a crime (M.S. sections 609.2661 to 609.268)

Solicitation, inducement and promotion of prostitution or any related offenses, disorderly house, criminal sexual conduct (M.S.sections 609.322 to 609.3451)

Solicitation of children to engage in sexual conduct, incest, malicious punishment of a child, or neglect or endangerment of a child (M.S. sections 609.352, 609.365, 609.377, and 609.378)
Use of minors in sexual performance, possession of pictorial representation of minors (M.S. sections 617.246 to 617.247)
Theft, possession of shoplifting gear (M.S. sections 609.52 and 609.521)
Arson, burglary (M.S. sections 609.5612 to 609.563 and 609.582)
Forgery or aggravate forgery (M.S. sections 609.625 or 609.63)
Terroristic threats; interference with privacy; obscene or harassing phone calls; letter, telegram, or package opening, harassment (M.S. sections 609.713, 609.746, 609.79, 609.795)
Indecent exposure; obscene materials and performances; indecent literature, distribution; harmful material display and
dissemination to minors? (M.S. sections 617.23, 617.241, 617.243, 617.293)
Attempts or conspiracy? (M.S. sections 609.17 to 609.175)

4. Subject of an investigation for or admission to abusing or neglecting an adult or child (M.S. section 260.221, paragraph b).

5. Do you have a mental illness or mental condition as diagnosed by a psychiatrist or licensed psychologist that has documented behaviors that would jeopardize the health, rights, or safety of residents? (9555.6125, Subp. 3, Sect. B)

6. Abuse prescription drugs or use controlled substances (M.S. Chapter 152) or alcohol to the extent that it would interfere with the health, safety, and rights of adults and children served

Signature/Date: *

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Interview Questions (Written Portion)

Please respond to the following quesitons. Keep in mind when completing these questions, this is an example of your writing skills as well as your personal statement so use complete sentences and complete thoughts.

Please share with us contributions you have made to your community (volunteer experience) and how that has impacted your life.

What do you consider to be your biggest accomplishment? Explain

Additional Comments:

Applicant Data Survey (completion of this information is voluntary)

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital status, veteran status, sexual orientation, or any other legally protected status.

As required, we comply with government regulations including Affirmative Action obligations where they apply.

In an effort to comply with requirements regarding government record keeping reporting and other legal obligations, we ask that you complete the applicant data survey.

Your cooperation is appreciated.

Please advise that your survey is NOT a part of your official application for employment. It is considered confidential information that will not be used in any hiring decision.

Date:

Position Applying For:

Referral Source:

Name of Referral Source (If Applicable):

First Name

Last Name

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Check One:

Male

Female

Non-Binary

Check One:

Disabled

Non-Disabled

Check one of the following Race/Ethnic Groups:

Thank you for Applying with Trillium Works!, Inc.

Trillium Works! Inc. 4629 Airpark Blvd Duluth, MN 55811 218-722-5009 info@trilliumservice.com

Return Employee	Indeed
Recruitment Booth	MN Workforce Center
Past Employee Referral	Employee Referral (please list name in Other box below)
Radio	Television
College Ad	Internet Ad
Facebook	Instagram
Other: Other:

Morning (6am-9am)	Day (8am-4pm)
Swing (2pm-10pm)	Overnight (10pm-8am)
Any

Person Centered Planning	Person Centered Thinking
PATH	MAPS
ELP/Picture of A Life	Medication Administration
CPR Certified	First Aid
Other: Other:

Program Counselor	Job Coach
Awake Overnight	Asleep Overnight
Respite Only	Management
Administrative

Return Employee	Indeed
Recruitment Booth	MN Workforce Center
Past Employee Referral	Employee Referral
Radio	Television
College Ad	Internet Ad
Facebook	Instagram
Other: Other:

Hispanic or Latino	Asian
American Indian/Alaska Native	Native Hawaiian or Other Pacific Islander
Black or African American	White