Application for Services

Winona ORC Industries welcomes you as an applicant. It is the policy of Winona ORC Industries to provide equal opportunity to all applicants. Winona ORC Industries will not discriminate against or harass any employee or application because of race, color, creed, religion, national origin, sex, sexual orientation, disability, age, marital status, or status with regard to public assistance.

To apply, please fill out the form below or download and print out the application and mail to our office.

Download Application PDF

Winona ORC Industries
Attn: Director of Client Services
1053 E Mark Street
Winona, MN 55987
[email protected]

Referral Date:

MM slash DD slash YYYY

Referred By:

First Last

Personal Information

Name

First MI Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Home Phone

Cell Phone

Email(Required)

Winona ORC Industries provides employment and skills training to individuals with disabilities. In order to be eligible to receive these services at Winona ORC, you must have medical documentation of a disability.

Only U.S. citizens or aliens who have a legal right to work in the U.S. are eligible for employment. Can you, upon employment, provide genuine documentation establishing your identity and eligibility to be legally employed in the United States?

Yes

If you are under age 18, please state your age?

If under 18, can you supply your certificate of age or working papers?

Yes

If you are under 25, have you been evaluated by Vocational Rehabilitation Services and deemed unable to work in integrated, competitive employment (community work)?

Yes

Have you ever applied at or worked for Winona ORC before?

Yes

Do you have a Vocational Rehabilitation Services Counselor?

Yes

Vocational Rehabilitation Services Counselor

Name

Phone

Do you have a Guardian?

Yes

Guardian Information

Name

Phone

Company

Do you have a County Case Manager?

Yes

County Case Manager Information

Name

Phone

County

Applicants may be placed on a waiting list.

Funding

DD Waiver

CADI Waiver

Extended Employment

Other

Explain:

Transportation to/from work:

Drive

City Transit Bus

WORC Bus

Other (Family, friend, bike, walk, etc)

Scheduling Information

Part-time

Full-time

Please list your available times below:

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Hours Requested

Education

High School

Name of School

Location

Years Attended

Graduate?

Degree

Vocational School

Name of School

Location

Years Attended

Graduate?

Degree

College/University

Name of School

Location

Years Attended

Graduate?

Degree

Employment History

Employer #1 - Most Recent

Company

Supervisor

Title

Phone

Employer Address #1

Street Address City State ZIP Code

Your Responsibilities

How long did you work there?

Start and end dates

Reason for Leaving:

Employer #2

Company

Supervisor

Title

Phone

Employer #2 Address

Street Address Address Line 2 City State ZIP Code

Your Responsibilities

How long did you work there?

Start and end dates

Reason for Leaving:

Employer #3

Company

Supervisor

Title

Phone

Employer Address #3

Street Address Address Line 2 City State ZIP Code

Your Responsibilities

How long did you work there?

Start and end dates

Reason for Leaving:

References (Excluding Relatives)

Please add three References

Name

Occupation

Phone

Applicants Statement(Required)

I authorize investigation of allstatements contained in this application asmay be necessary in arriving at a decision.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Winona ORC participates in the E-verify program through United States Citizenship and Immigration Services -Department Homeland Security.

I certify that answers given herein are true and complete to the best of my knowledge.

Name(Required)

First Middle Last

Date(Required)

MM slash DD slash YYYY

Applicant Survey

Winona ORC Industries, Inc. is an equal opportunity employer. As required by law, we must record certain information to be made a part of our affirmative action program.

Applicants for employment are invited to participate in the affirmative action program by reporting their status as a minority. In extending this invitation, we advise you that: (a) workers (applicants) are under no obligation to respond but may do so in the future if they choose; (b) responses will remain confidential within the human resource department; and (c) responses will be used only for the necessary information to include in our affirmative action program. We are a company that values diversity. We actively encourage women, minorities, veterans and disabled employees to apply.

Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment.

Race/Ethnicity (Check all that apply)

Hispanic or Latino

White

Black or African American

Native Hawaiian or Pacific Islander

Asian

American Indian or Alaskan Native

I prefer not to answer.

Gender

Female

Male

I do not wish to self-identify