Hr 116 Application for Employment with Hills and Dales

PERSONAL INFORMATION

Application Date: ___________ POSITION APPLYING FOR: ______________________________

1. ____________________________________________________________________________________

Last Name First Name Middle Name

2. ____________________________________________________________________________________

Street Address City State Zip Code

3. ________________________________________ 4. ____________________________________

Primary Phone Number Secondary Phone Number

5. Type of employment desired: ____ Full time ____ Part time ____ Seasonal

6. Type of shift desired: ____ First Shift ____ Second Shift ____ Third Shift

12. How did you hear about this position, please check the appropriate box?

[ ] Access Dubuque [ ] School [ ] Career/Job Fair [ ] Website [ ] Walk-in

[ ] Newspaper, list: ______________ [ ] Other, list: _____________

[ ] Employee, name: ______________

EMPLOYMENT RECORD

Employer Address __________________________________________________________________

Phone Number __________________________________________________________________

Position Held __________________________________________________________________

Immediate Supervisor ____________________________________________________________

Description of Duties ____________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Reason for Leaving ____________________________________________________________

Dates of Employment ____/____/____ to ____/____/____ Final Wage ____________

Name of Employer __________________________________________________________________

Employer Address __________________________________________________________________

Phone Number __________________________________________________________________

Position Held __________________________________________________________________

Immediate Supervisor ____________________________________________________________

Description of Duties ____________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Reason for Leaving ____________________________________________________________

Dates of Employment ____/____/____ to ____/____/____ Final Wage ____________

Name of Employer __________________________________________________________________

Employer Address __________________________________________________________________

Phone Number __________________________________________________________________

Position Held __________________________________________________________________

Immediate Supervisor ____________________________________________________________

Description of Duties ____________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Reason for Leaving ____________________________________________________________

Dates of Employment ____/____/____ to ____/____/____ Final Wage ____________

May inquiry be made of your present employer regarding your character, qualifications and record of employment? Yes ____________ No ____________

May inquiry be made of your past employer(s) regarding your character, qualifications and record of employment? Yes ____________ No ____________

EDUCATION

TRAINING

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

REFERENCES

Name Telephone Number Title Years Known

1.________________________________________________________________________________________

2.________________________________________________________________________________________

3.________________________________________________________________________________________

Have you ever plead “guilty” or “no contest” to, or been convicted of a crime, in any state, include deferred judgments? Yes ____ No ____

Do you have a record of founded child or dependent adult abuse, in any state? Yes ____ No ____

If yes to either question, please provide date(s) and details

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

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:

1. 
   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.
   
2. 
   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.
   
3. 
   I authorize such checks to be conducted.
   
4. 
   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.
   
5. 
   I understand any offer of employment is contingent on acceptable outcomes of such tests and inquiries as stated above.
   
6. 
   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 ________________________________________________________

05/04;04/06;09/06;02/07; 01/11

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:

1. 
   Where is smoking prohibited under the Smoke-free Air Act:
   

• 
  Public places include
  
  • 
    Financial institutions
    
  • 
    Restaurants
    
  • 
    Bars
    
  • 
    Public and private schools
    
  • 
    Health care provider locations
    
  • 
    Laundromat
    
  • 
    Public transportation facilities
    
  • 
    Aquariums, galleries, libraries and museums
    
  • 
    Retail service establishments
    
  • 
    Retail stores
    
  • 
    Shopping malls
    
  • 
    Theaters, concert halls, auditoriums, sporting arenas, and other
    

performance venues

• 
  Polling places
  
• 
  Convention facilities
  
• 
  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
  
• 
  Outdoor serving or seating areas of restaurants
  
• 
  Public transit stations, platforms, and shelters
  
• 
  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.

PLEASE PRINT

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.

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