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Application for Employment

Please print; use additional sheets if necessary. Conditions of employment are stated at the end of this form. Please read carefully before you sign and submit this application.

Date of application:

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Position(s) applied for:

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PERSONAL INFORMATION

First Name

Please type your first name.

Middle Name

Please type your last name.

Last Name

Please type your last name.

Street Address:

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City:

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State:

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Zip:

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Phone:

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E-mail

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Are any of your relatives presently employees, board members, or service recipients with our agency?

Yes No Invalid Input

If yes, name of relative:

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Have you ever worked for our agency before?

Yes No Invalid Input

If yes, position title and dates of employment:

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Have you ever applied for employment with our agency before?

Yes No Invalid Input

If yes, when:

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Referral Source
(if referred by a current employee list their name):

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EMPLOYMENT HISTORY
(Starting with Most Recent)

Name of Employer:

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Address:

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City:

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State:

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Zip:

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Type of Business:

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Telephone Number.:

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Your Supervisor’s Name:

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Your Position Duties:

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Date of Employment:

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Date of Employment:

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Reason for Leaving:

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Name of Employer:

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Address:

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City:

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State:

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Zip:

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Type of Business:

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Telephone Number.:

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Your Supervisor’s Name:

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Your Position Duties:

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Date of Employment:

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Date of Employment:

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Reason for Leaving:

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Name of Employer:

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Address:

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City:

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State:

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Zip:

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Type of Business:

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Telephone Number.:

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Your Supervisor’s Name:

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Your Position Duties:

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Date of Employment:

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Date of Employment:

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Reason for Leaving:

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REFERENCES
(Do Not List Relatives)

Reference 1

Name:

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Address:

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City:

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State:

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Zip:

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Occupational Title/Relationship:

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Telephone Number.:

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Length of Relationship:

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Reference 2

Name:

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Address:

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City:

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State:

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Zip:

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Occupational Title/Relationship:

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Telephone Number.:

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Length of Relationship:

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PLEASE READ AND SIGN BELOW

In consideration of the acceptance and processing of my application for employment, and of my employment with Search Inc. (Search), if I am employed, I hereby warrant and represent as follows:

1. Certification. I certify that I have not knowingly withheld any information that might adversely affect my chances for employment with Search and that the information given by me is true and correct without any mental reservation whatsoever. I understand that any omission or misstatement of material fact on my employment application, resume, or any other document used to secure employment with Search, Inc., or during any pre-employment interview, shall be grounds for rejection of my application or for immediate discharge if I am hired, regardless of the time elapsed before discovery.
I understand that if I am hired; my employment with Search requires submission to fingerprinting and a criminal background check per Search’s license through the Illinois Department of Public Health (IDPH) and should any “disqualifying conviction(s) ” as defined by the IDPH be in evidence on my record it will prevent me from starting or continuing employment with Search. I also understand that if I am hired; my employment with Search requires submission of a Child Abuse and Neglect Tracking System (CANTS) check and I will be unable to start or continue employment with Search, Inc. should a finding/indication/hit of abuse or neglect be returned.
2. Reference and Background Check. I authorize Search to thoroughly investigate my references, work record, education, and any other matters related to my suitability for employment. I also authorize my former employers to disclose to Search any and all of my employment records, including disciplinary reports and letters of reprimand, without giving me notice of such disclosure. I hereby fully release and discharge Search, my former employers, their respective officers, employees and agents, and all other persons and entities, from any and all claims, demands, and liabilities arising out of or in any way related to such investigation or disclosure.
I understand that if I am hired; my employment with Search requires submission to fingerprinting and a criminal background check per Search’s license through the Illinois Department of Public Health (IDPH) and should any “disqualifying conviction(s)” as defined by the IDPH be in evidence on my record it will prevent me from starting or continuing employment with Search. I also understand that if I am hired; my employment with Search requires submission of a Child Abuse and Neglect Tracking System (CANTS) check and I will be unable to start or continue employment with Search, Inc. should a finding/indication/hit of abuse or neglect be returned.
3. At-Will Employment. I understand and agree that if I am hired, my employment and compensation are for no definite or determinable period and may be terminated at any time, with or without cause, warning or notice, at the option of either myself or Search. I further understand and agree that no representative of Search is authorized to make any binding representations or agreements, whether oral or written, contrary to the foregoing or purported to guarantee any particular benefits, terms, or conditions of employment.
4. Re-Application Policy. I understand that under Search's policy, this application will remain active for only sixty (60) days. Therefore, if I have not been hired within sixty (60) days of the date of this application and I still wish to be considered for employment with Search, I understand that I will need to complete and submit a new employment application.

Applicant Signature

Please enter your name as a digital signature for this form

Date:

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THIS APPLICATION FOR EMPLOYMENT IS GOOD FOR ONE YEAR. CONSIDERATION FOR EMPLOYMENT AFTER SIX MONTHS REQUIRES A NEW APPLICATION.

Application for Employment

PERSONAL INFORMATION

GENERAL INFORMATION

POSITION SPECIFICATIONS

POSITION CRITERIA

Are you willing to provide care to individuals, such as:

Are you willing to assist individuals that have behavioral challenges if:

Are you willing to assist individuals that have physical challenges by:

ATTENDANCE AND PUNCTUALITY INFORMATION

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