Developmental Disabilities Job Opportunities

Date(Required)

Name

First Middle Last Maiden

Present Address

Street Address City State ZIP Code

How long at present address?

Social Security No.

Phone

If under 18, please list age

Position Applied For

Salary Desired

Days/hours Avaiable to Work

No Pref

Thursday

Monday

Friday

Tuesday

Saturday

Wednesday

Sunday

How many hours can you work weekly?

Can you work nights?

Employment Desired

FULL-TIME ONLY

PART-TIME ONLY

FULL OR PART-TIME

When available for work?

EDUCATION

High School

Number of Years Completed

Diploma

High School Address

Street Address City State / Province / Region ZIP / Postal Code

College

Number of Years Completed

Major & Degree

College Address

Street Address City State / Province / Region ZIP / Postal Code

Business or Trade School

Number of Years Completed

Major & Degree

Business or Trade School Address

Street Address City State / Province / Region ZIP / Postal Code

Professional School

Number of Years Completed

Major & Degree

Professional School Address

Street Address City State / Province / Region ZIP / Postal Code

Have you ever been convicted of a crime?

Yes

If yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed, and type(s) of rehabilitation.

Do you have a driver's license?

Yes

What is your means of transportation to work?

Driver's License Number

State of Issue

Expiration Date

Additional Licenses

Operator

Commercial (CDL)

Have you had any accidents during the past 3 year?

How many?

Have you had any moving violations during the past 3 years?

How many?

OFFICE ONLY

Typing

Yes

Word Per Minute

Personal Computer

Yes

Computer Type

Mac

Other Skills

Please list two references other than relatives or previous employers.

Name

Position

Company

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space below to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.

MILITARY

Have you ever been in the armed forces?

Yes

Are you now a member of the national guard?

Yes

Specialty

Date Entered

Discharge Date

WORK EXPERIENCE

Please list your work experience for the past five years beginning with your most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary.

Name of Employer

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Name of Last Supervisor

Employment Dates - From

Pay or Salary - Start

Final

Your Last Job Title

Reason for Leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Name of Employer

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Name of Last Supervisor

Employment Dates - From

Pay or Salary - Start

Final

Your Last Job Title

Reason for Leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Name of Employer

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Name of Last Supervisor

Employment Dates - From

Pay or Salary - Start

Final

Your Last Job Title

Reason for Leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Name of Employer

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Name of Last Supervisor

Employment Dates - From

Pay or Salary - Start

Final

Your Last Job Title

Reason for Leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Did you complete this application yourself?

Yes

May we contact your present employer?

Yes

If not, who did?

PLEASE READ CAREFULLY

APPLICATION FORM WAIVER

In exchange for the consideration of my job application by Independent Horizons (hereinafter called “the Company”), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Independent Horizons, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and the relationship cannot be altered except by a written instrument signed by the President /General Manager of the Company. Both the undersigned and Independent Horizons may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contract.

I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of job-related physical examinations. I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it.

I further understand that my employment with the Company shall be probationary for a period of six (6) months, and further that at any time during that probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.

Signature

Date

This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age of or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

Thank you for completing this application form and for your interest in our business.

Careers in I/DD Care

APPLICATION FOR EMPLOYMENT

Days/hours Avaiable to Work

EDUCATION

OFFICE ONLY

MILITARY

WORK EXPERIENCE

Why Employees Love Independent Horizons

Why Employees Love Independent Horizons

Why Employees Love Independent Horizons

Why Employees Love Independent Horizons

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