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Employment Application
Step
1
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6
16%
Name
*
First
Middle
Last
Your Phone
Your Email
*
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
What position are you applying for?
Availability
Days
Evenings
Overnights
Capacity
Part-time
Full-time
Temporary/PRN
How did you hear about us?
Radio
TV
Social Media
Friend/Family
Search Engine
Other
Other Source
Have you ever filed an application with us before?
No
Yes
Yes, Dates
Have you ever been employed with us before?
No
Yes
Yes, Dates
Are you capable of performing the essential functions of this position?
No
Yes
Are you a citizen of the United States?
No
Yes
If no, are you authorized to work in the U.S.?
No
Yes
Have you ever been convicted of a felony?
No
Yes
If yes, explain
Soonest Date Available to Start
MM slash DD slash YYYY
Indicate any foreign languages you can speak, read and/or write.
References (Cannot be related to you or a previous employer.)
Reference - 1
Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Reference - 2
Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Reference - 3
Name
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Education: High School
Name
Location
Diploma/Degree
Training/Honors/Etc.
Are you currently enrolled or graduated?
Currently Enrolled
Graduated
Education: College/University
Name
Diploma/Degree
Training/Honors/Etc.
Are you currently enrolled or graduated?
Currently Enrolled
Graduated
Education: Additional Schooling
Name
Location
Diploma/Degree
Training/Honors/Etc.
Are you currently enrolled or graduated?
Currently Enrolled
Graduated
Employment Experience
Start with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, handicap or other protected status.
Employment - 1
Employer Name
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Job Title
Supervisor
Reason for Leaving
Date Began
MM slash DD slash YYYY
Date Ended
MM slash DD slash YYYY
Starting Rate
Work Performed/Responsibilities:
Can we contact this employer?
Yes
No
Employment - 2
Employer Name
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Job Title
Supervisor
Reason for Leaving
Date Began
MM slash DD slash YYYY
Date Ended
MM slash DD slash YYYY
Starting Rate
Work Performed/Responsibilities:
Can we contact this employer?
Yes
No
Employment - 3
Employer Name
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Job Title
Supervisor
Reason for Leaving
Date Began
MM slash DD slash YYYY
Date Ended
MM slash DD slash YYYY
Starting Rate
Final Rate
Work Performed/Responsibilities:
Can we contact this employer?
Yes
No
Special Skills and Qualifications
Summarize special job-related skills and qualifications acquired from employment or other experiences.
If you were unemployed at any time since leaving school, please indicate what you were doing during this time.
Upload Resume
Acceptable File Formats: pdf, doc, docx, jpg, jpeg
Accepted file types: pdf, doc, docx, jpg, jpeg, Max. file size: 2 MB.
Applicant's Statement & Agreement
I certify that the answers given in this Application for Employment are true and complete to the best of my knowledge. The facility may investigate all statements made in this Application. The facility is required by law to check for any criminal or abuse record. I understand that any false or misleading information provided can result in a decision not to hire, immediate discharge if hired, and civil or criminal penalties in appropriate cases.
I understand that I will be required to fulfill all aspects of any job if I am hired to perform the job. I understand that the failure to fulfill any aspect of the job may result in termination. I also understand that I may be required to take a physical examination conducted by a physician of the employer’s choosing after I am given a qualified offer of employment and that a health screening for diseases such as TB is required.
I understand that this Application is not a contract of employment; that if hired, regardless of any oral representations to the contrary, the employment relationship between myself and the facility is terminable at will; that I have the right to terminate my employment at any time for any reason, and the facility retains the same right. Any changes to this employment relationship must be in writing. I understand that if hired I am required to abide by all rules and regulations of the facility.
If hired, you will be required to submit documents sufficient to establish employment authorization and identity compliance with the Immigration Reform and Control Act of 1986. While you need not provide this proof of citizenship or immigration status at the time you are interviewed, please be prepared to assure us that you can do so immediately upon being hired.
AN EQUAL OPPORTUNITY EMPLOYER
This facility is an equal opportunity employer. Employment decisions are made without regard to age, race, color, sex, sexual orientation, gender identity, national origin, religion, disability, status as a disabled Vietnam era veteran, or other categories as specified by law.
Please sign your name agreeing to the above statement
*
Name
This field is for validation purposes and should be left unchanged.
Employment
Follow Us
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(319)396-3692
Home
About Us
Locations
Services
Apartments
FAQS
Employment
News
Contact Us
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