Hillcrest Family Services

Application for Employment

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

Attention 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 and others that may be available. Please review your application to ensure that it is: complete, correct, and signed prior to submitting it. Once your application materials have been reviewed, a confirmation card is sent via USPS.

Name: Last: First: Middle:
Home Phone: Other Phone: Email:
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
Do you have a record of founded child or dependent adult abuse or have you ever been convicted of crime in this state or any other state? 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 Has your driver's license ever been revoked or suspended?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
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


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
College or university Yes
Graduate / Business School Yes
Other (Specify) Yes

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

Last wage or salary: $ per

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

Last wage or salary: $ per

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

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.

Physical Examination/Record Check/Drug Free Employer
Hillcrest Family Services (HFS) may require successful completion of a physical examination or a health care provider's statement before hire. HFS may require criminal history, child and dependent adult abuse, sexual offender registry, and motor vehicle record checks in addition to professional references. HFS will verify exclusionary status prior to hire under HHS-OIG provisions. HFS is a drug free employer. Any offer of employment is contingent upon successful completion of record checks and drug screen.

Iowa Smokefree Air Act
I recognize that HFS is an Iowa Employer and in accordance with the Smokefree Air Act (Iowa Code 142D), I understand that by providing services for Hillcrest Family Services, either in a paid or non-paid capacity, I am prohibited from smoking in all enclosed places and on the grounds.

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 will be paid by direct deposit and I can 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
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