Date:

Name: Last:   First: Middle: SSN:           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 Hillcrest 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 employed now?	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 offense and the disposition of the case

Answer the following questions if applicable to position:

1. Do you have a valid driver's license?	Yes No
2. Can you provide your own transportation on the job?	Yes No
3. Driver's license number:
4. State of issue:
5. Has your driver's license ever been revoked or suspended?	Yes No
Date:
6. Have you ever been on risk insurance?	Yes No

RECORD OF EDUCATION

School	Name and address of school	Number of years attended	Applicable Coursework	Did you graduate?	Specify Degree / Major
High School				Yes No
College or university				Yes No
Graduate School				Yes No
Other (Specify)				Yes No

EMPLOYMENT DATA (Last employer first)

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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

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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

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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

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I hereby grant permission to contact my current employer

 

REFERENCES - Two personal, three professional (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.

HFS may require successful completion of a physical examination or a health care provider's statement before hire. HFS may require criminal background checks, child and dependent adult abuse checks, motor vehicle record check and professional references before regular hire. Hillcrest is a drug free employer. Any offer of employment is contingent upon background checks and drug screen. 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 disability. HFS will promote the full realization of equal opportunity through positive, continuing programs in every department.

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

How did you hear about the employment opportunities at Hillcrest?

Newspaper	Friend	Hillcrest Staff Member(Name)
Job Service	College or University	Other

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, etc.)

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.

G. How did you learn about this job?

Iowa Workforce Development Center

Hillcrest Family Services employee

Internet/Website

College, University or Area Community college placement office

Newspaper, periodical or trade journal

Career Fair

Hillcrest Family Services website