Employee Application

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Bobbi Chipman, Human Resources Director

For more information on employment opportunities:

Employment Application

Position(s) Applied For

Date of Application

Last Name

First Name

Middle Name

Address

Apt. #

City

State

Zip Code

Home Phone

Cell Phone

Email Address

Are you 18 years of age or older? (If you are hired, you may be required to submit proof of age)

Yes

If hired, can you furnish proof you are eligible to work in the United States?

Yes

College History:

Name of College Attended:

Years Attended

Diploma/Degree/Cert. Earned? Please list:

Subjects Studied/Majors

Voc. or Tech. School History:

Name of Voc. or Tech. School Attended:

Years Attended

Diploma/Degree/Cert. Earned? Please list:

Subjects Studied/Majors

High School History:

Name of High School Attended:

Years Attended

Diploma/Degree/Cert. Earned? Please list:

Did You Graduate?

Yes

What skills or additional training do you have that are related to the job for which you are applying?

What machines or equipment can you operate that are related to the job for which you are applying?

List professional, trade, business, or civic activities and offices held (do not include labor organizations and memberships which reveal race, color, religion, national origin, sex, age, disability, or other protected status):

Have you ever worked under any other name?

Yes

If yes, please give name(s):

Are you presently employed?

Yes

If you are presently employed, may we contact your present employer?

Yes

Have you ever been fired from a job or asked to resign?

Yes

If yes, please explain:

Reference #1:

Name:

How do you know this person?

Address:

City/State:

Phone Number:

Reference #2:

Name:

How do you know this person?

Address:

City/State:

Phone Number:

Reference #3:

Name:

How do you know this person?

Address:

City/State:

Phone Number:

State any additional information you feel may be helpful to us in considering your application:

BE SURE TO READ EACH STATEMENT CAREFULLY BEFORE SIGNING

I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.

I authorize and agree to cooperate in a thorough investigation of all statements made herein and other matters relating to my background and qualifications. I understand that any investigation conducted may include a request for employment and educational history, credit reports, consumer reports, investigative consumer reports, driving record, and criminal history.

I understand I may be required to successfully pass a drug-screening examination. I hereby consent to a pre-and/or post-employment drug screen as a condition of being hired or of my continued employment, if required.

I acknowledge that I have been informed of prohibitions of the Iowa Smokefree Air Act.

I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITHOUT NOTICE.

I have read, understand, and by my signature consent to these statements.

Sign Here

Date

Please check all shifts that you are able to work.

Only Residential Facilitators have set schedules; Direct Care staff do not have set schedules.

If you want 40 or more hours you need to provide 80 or more hours of availability.

(You should be available for twice as many shifts as you want).

Please answer the below questions:

What is the ideal number of hours you would like to work in a week?

What is the first day you are available to work?

Are you able to work at a location that requires lifting/transferring of members?

Are you comfortable working with members of the opposite sex?

I, the undersigned, agree to the above availability. I understand that any changes made to my availability before my potential date of hire need to be approved by the Human Resources Coordinator.

Sign Here