We consider applicants for all positions with out regard to race, color, religion, creed, gender, national origin, age, disability, maritial 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

Type of Employment *
Position Applying For: *
How did you hear about us? (Check All that Apply) *
 
Have you been employed with Trillium previously? *
 
Are you related to anyone receiving services from Trillium? *
 
Are you legally authorized to work in the United States? *
Are you currently employed? *
If currently employed, may we contact your employer? *
Do you have a valid driver's license? *
Do you have use of an insured vehicle? *

Availability

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Shift preference: *
Days Available *

Employment History

Employer 1
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May we contact? *
Employer 2
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 +
May we contact? *
Employer 3
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May we contact? *

Education

Last Year Completed *
Did you Graduate: *
Last Year Completed
Did you Graduate:
Last Year Completed
Did you Graduate:

References

Professional Reference 1
Professional Reference 2
Personal Reference 3

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) *
What are some of your hobbies? (Check as many as apply to you) *
What are some of your hobbies? (Check as many as apply to you) *
Specialized Skills: Check Skills (If Applicable) *
 

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.

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.
Position Applying For:
Referral Source:
 
Check One:
Check One:
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
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