Equal access to programs, services and employment is available to all persons. Those applicants requiring accommodation to the application and/or interview process should notify a representative of the Human Resource Department.
PLEASE READ BEFORE COMPLETING:
Complete this application in detail. Do not leave sections blank. Simply write N/A if not applicable.
Legibly print or type your responses, no cursive please.
Resumes may be attached but does not substitute for a completed application.
Submission of an application does not guarantee an interview, rather consideration for open positions.
Hills and Dales hires only U.S. Citizens and Aliens lawfully authorized to work in the United States. All new employees must complete the Federal I-9 form which verifies the person’s identity and employment eligibility.
Hills and Dales is an Equal Opportunity Employer.
Application Date: ___________ POSITION APPLYING FOR: ______________________________
5. Type of employment desired: ____ Full time ____ Part time ____ Seasonal
6. Type of shift desired: ____ First Shift ____ Second Shift ____ Third Shift
7. Are you available to work weekends: ____ Yes ____ No
8. Have you submitted an application here before? ____ Yes ____ No
If yes dates: ______________________________________________________
9. Have you ever worked here before? ____ Yes ____ No
If yes dates: ______________________________________________________
10. Date available for work: __________________________
11. What is your desired salary range or hourly rate of pay? $_____________ Per __________
List any other names, last or first, that you have gone by ____________________________________________
Hills and Dales is licensed by federal and state government regulations for multiple service programs. Regulations governing our facility require that we prohibit the employment of individuals with a conviction or prior employment history of child or client abuse, neglect or mistreatment.
By affixing my signature below, I understand:
If my application for employment is considered, a check of my background will be conducted to determine if there has been a conviction or prior employment history of child, client or dependent adult abuse, neglect or mistreatment. A criminal record check will also be conducted. A check of the Office of Inspector General’s exclusionary list for Medicaid Fraud may also be completed.
If at any time a conviction or prior employment history of child, client or dependent adult abuse, neglect or mistreatment is discovered, my employment with Hills and Dales may be terminated immediately. I also understand that if at any time it is discovered that I am on the Office of Inspector General’s exclusionary list for Medicaid Fraud, my employment with Hills and Dales may be terminated immediately.
I authorize such checks to be conducted.
I will be required to participate in a drug screening as part of an agency physical only if an offer of employment has been extended.
I understand any offer of employment is contingent on acceptable outcomes of such tests and inquiries as stated above.
I understand that part of my interview may include meeting residents and consumers and that I may observe and hear information that may be confidential during that time. I understand that I am not to share this information with any one.
CERTIFICATION OF APPLICANT
Please read carefully
I HEREBY CERTIFY that this application contains no misrepresentations or falsifications and that the information given by me is true and complete to the best of my knowledge and belief. I am aware, that should an investigation at any time disclose any such misrepresentation or falsification, my application may be rejected and I may be dismissed from my employment with Hills and Dales. I further authorize Hills and Dales to make all necessary and appropriate investigations to verify the information contained herein.
Signature ____________________________________________ Date ___________________
AUTHORIZATION AND RELEASE
Having made application for employment and desiring Hills and Dales to be informed as to my record(s), I hereby authorize Hills and Dales to investigate my record and I further authorize the addressed individual, company, or institution to furnish Hills and Dales with any information which may concern my employment record, and do hereby release the addressed individual, company, or institution and all persons whomsoever from any damage on account of furnishing such information.
Signature of Applicant _________________________________________________
Date Signed ________________________________________________________
The Iowa Smoke-free Air Act Prohibited under the Act:
On July 1, 2008 the Smoke-free Air Act goes into effect statewide. This handout
will provide information about what the Act:
Where is smoking prohibited under the Smoke-free Air Act:
All other enclosed areas to which the public is invited or permitted to enter
Enclosed areas within places of employment such as work areas, private offices, conference and meeting rooms, classrooms, auditoriums, employee lounges and cafeterias, hallways, medical facilities, restrooms, elevators, stairways, and vehicles owned, leased for provided by the employer that are not otherwise exempt
Seating areas of outdoor sports arenas, stadiums, amphitheaters and ther outdoor entertainment venues
School grounds, including parking lots, athletic fields, and vehicles located on school property
Grounds of any public building owned, leased or operated or controlled by the state government or its entities
Private residence used as child care facilities, child care homes, or health provider location
APPLICANT EEO OR AFFIRMITIVE ACTION INFORMATION
It is the policy of Hills and Dales to provide equal employment opportunity to all qualified applicants for employment without regard to race, color, religion, national origin, citizenship, sex, age, veteran status, disability or any other similarly protected status.
COMPLETION OF THIS FORM IS VOLUNTARY AND IN NO WAY AFFECTS THE DECISION REGARDING YOUR APPLICATION FOR EMPLOYMENT. THIS FORM IS CONFIDENTIAL AND WILL BE MAINTAINED SEPARATELY FROM YOUR APPLICATION FORM.
Name_____________________________________________________ Date ________________
Last First Middle
Position applied for: ___________________________________________________________
1. What is your race/ethnic origin?2. What is your gender?
O Hispanic or Latino O Female
O White (not Hispanic or Latino) O Male
O Black or African American (not Hispanic or Latino)
O Native Hawaiian or Other Pacific Islander (not Hispanic or Latino) 3. Age 40 & Over?
O Asian (not Hispanic or Latino) O Yes
O American Indian or Alaskan Native (not Hispanic or Latino) O No
O Two or More Races (not Hispanic or Latino)
4. Have you served and been honorably discharged from the Military forces of the United States during any of the following periods? ____ Yes ____ No
A. December 7, 1941 – December 31, 1946 D. June 25, 1950 – January 31, 1955
B. February 28, 1961 – May 7, 1975 E. August 24, 1982 – July 31, 1984
C. December 20, 1989 – January 31, 1990 F. August 2, 1990 -
5. Are you a disabled veteran? ____ Yes ____ No
A person entitled to disability compensation under laws administered by the Veteran’s Administration for disability rated at 30% or more, or a person whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty.
6. Do you have a mental or physical disability? ____ Yes ____ No
A person who has a mental or physical impairment that substantially limits one or more major life activities, who has a record of such impairment, or who is regarded as having such an impairment.