Hillcrest Family Services Online Gift Mailing List

Application for Employment

Hillcrest Family Services
2005 Asbury Rd., Dubuque, IA 52001

To Applicant: Thank you for your interest in Hillcrest Family Services. A clear understanding of your background and work history will help us in evaluating your qualifications for the position for which you are applying.

Name: Last: First: Middle:

Home Phone: Other Phone:

Present Address:

Street: City: State: Zip:

Position applied for:

Times or days you are unable to work:

Type of employment you are seeking:

Full-time Part-time On-Call Temporary / Seasonal

What are your wage or salary expectations? $ per
Have you ever worked for HFS before? Yes No
If yes, give the dates of employment and the position(s) held:

Available for employment immediately?	Yes No
If not, how soon?
Are you on layoff and subject to recall?	Yes No
Are you now employed?	Yes No
Are you at least 18 years old?	Yes No
Have you ever been convicted of an aggravated misdemeanor or felony?	Yes No

If yes, give the date, nature of offense and the disposition of the case:

Have you ever been convicted of a crime involving the mistreatment or exploitation of a child?

Yes No

If yes, explain nature of offence and the disposition of the case:

Are you EITHER a U.S. citizen OR legally authorized to work in the United States?

Yes No

Answer the following questions if applicable to position:

1. Do you have a valid driver's license?	Yes No
2. State of issue:
3. Can you provide your own transportation on the job?	Yes No
4. Has your driver's license ever been revoked or suspended?	Yes No
Date:
5. Have you ever been on risk insurance?	Yes No
6. Are you physically or otherwise unable to perform the duties of the job for which you are applying?	Yes No

RECORD OF EDUCATION

School	Name and address of school	Number of years attended	Courses which may be of value in position for which you applied	Did you graduate?	Specify Degree / Major
High School				Yes No
College or university				Yes No
Graduate / Business School				Yes No
Other (Specify)				Yes No

EMPLOYMENT DATA (Last employer first)

Employer: Phone Number:
Address(Street, City, State, Zip)
Your Title: Supervisor's Name
From (Mo/Yr) To (Mo/Yr) Reason for leaving
Duties:

Last wage or salary: $ per

I hereby grant permission to contact my current employer

REFERENCES - Three professional, two personal (no relatives)

Name and Occupation	Address, City, State, Zip	Phone	No. Years Known?

The following information is important to you as an applicant for employment at Hillcrest Family Services. Please read carefully.

Fair Credit Reporting Act Information
Public Law 91-508 requires that we advise you that a routine inquiry may be made which will provide applicable information concerning character, general reputation, personal characteristics and mode of living. You have the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of any such investigative report that is made.

Physical Examination and Public Safety Check
For certain positions, HFS may require successful completion of a physical examination or a Doctor's statement before hire. Also, for certain positions, HFS may require a public safety check before regular hire.

Equal Employment Opportunity Statement/Drug Free Employer
Employment opportunities at HFS will continue to be open without regard to race, color, creed, religion, sex, age, national origin or handicap. HFS will promote the full realization of equal opportunity through positive, continuing programs in every department. Hillcrest is a Drug Free Employer. Any offer of employment is contingent upon background checks and drug screen.

Applicant's Statement
I hereby give HFS the right to make a thorough investigation of my past employment, education, and activities and I release from all liability all persons, companies, and corporations supplying such information. I indemnify HFS against any liability which might result from making such investigation. I understand that any false answer or statements or implications made by me in this application or other required documents shall be considered sufficient cause for denial of employment or discharge.

Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between HFS or myself or either employment or for the providing of any benefit. My signature acknowledges that I understand and accept the above statements regarding my rights as an applicant and HFS rights and policies.

Date Applicant's Name

Agreement Regarding Direct Deposit of Wages
I agree that if I become employed by HFS, that my wages can be paid by direct deposit of my wages and I will provide all necessary document and signatures to facilitate payment of my wages by direct deposit.

Date Applicant's Name

How did you hear about the employment opportunities at Hillcrest?

Newspaper	Friend	College or University	Job Service	Hillcrest Web Site
Hillcrest Staff Member			Other

Applicant Survey

Hillcrest Family Services is committed to Equal Employment Opportunity and Affirmative Action. Your response to the following questions is voluntary and will only be used for reporting requirements and affirmative action referrals. It is deemed confidential and refusal to provide information will not adversely affect you as an applicant. This section is removed before your application is processed.

A. As defined by the Equal Employment Opportunity Commission (EEOC), what type of position are you applying for?
Officials and Managers ( administrator, director, etc.)
Professionals (assistant administrator, teacher, dietitian, therapist, et.)
Technicians (dental hygienist, LPN, etc.)
Sales Workers (sales)
Office and Clerical (secretary/receptionist, bookkeeper, etc.)
Craft Workers (skilled) (auto body, carpenter, painter, etc.)
Operative (semi-skilled) (bus driver, machine operator, etc.)
Laborers (unskilled) (maintenance, etc.)
Service Workers (youth care worker, night monitor, counselors, teacher associate, mental health tech, etc.)

B. What gender are you?
Male
Female

C. What is your age?
Under 18
18-29
30-39
40-49
50-59
60-69
70 or over

D. What is your highest level of education?
0-8 years
9-12 years, but not a high school graduate
High school graduate or GED
Post high school vocational or business school
Some college, less than BS or BS degree
BA, BS or similar undergraduate degree
MA, MS or similar graduate degree
PhD, JD or similar professional degree
MD or similar professional degree

E. Do you have a disability that is a physical or mental impairment that substantially limits one or more major life activities; do you have a record of such an impairment, or are you regarded as having such an impairment?
Yes
No

F. Of which racial/ethnic group do you consider yourself a member of?
White (not of Hispanic origin) -
    All persons having origins in any of the original peoples of Europe, North Africa, or the Middle East.
African American (not of Hispanic origin) -
    All persons having origins in any of the African American racial groups of Africa.
Hispanic -
    All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin,
    regardless of race.
Asian or Pacific Islander -
    All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent,
    or the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands,
    and Samoa.
American Indian or Alaskan Native -
    All persons having origins in any of the original peoples of North America, and who maintain cultural
    identification through tribal affiliation or community recognition.