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Application

Disciples Benevolent Services is an equal opportunity employer


PERSONAL
Name:   Today's Date :

Have you ever used any other name(s) (such as nickname, alias, maiden or former name?  

If yes, please list them:  

Address:  

City:
   State:
   Zip:
  

Home Phone:
   Business Phone:
   Social Security:
  

Position applied for:  

Shift Availability:   Date you are available for work:  

How did you learn about Disciples Benevolent Services?  

Disciples Benevolent Services has a policy that regulates employing spouses or domestic partners of current employees.

Is your spouse or domestic partner currently employed by Disciples Benevolent Services?


Are you 18 years of age or older?  

Have you ever been convicted of a misdemeanor or felony?

(answering yes will not necessarily disqualify you for employment)

If yes, describe condition


Have you been fired or asked to leave a job within the last five (5) years?

If yes, please explain:


Has any action ever been brought by any agency to sanction you (including any fines or other penalties) or to exclude you from

participation in any locally, state, or federally funded program?

If yes, please explain:


Have you ever been formally disciplined in conjunction with a professional license held, forfeited a professional license, or had a

professional license revoked?

If yes, please explain:


EDUCATION
LEVEL
Name & location of school
Year Graduated
Major
Diploma/Degree
  
High School
 
College/University
 
College/University
 
Other Training/Education
 

SKILLS/SPECIALIZED TRAINING (If applicable)

MS Word Version , Typing words per minute, MS Excel , Lotus , 10 Key Calculator ,

MS Powerpoint , MS Access , MS Outlook

Additional skills / Specialized training?


EMPLOYMENT RECORD
(Name last employer first. Outline employment record for the last ten (10) years.)

Name of employer Street Address City State Zip  

Dates employed

from to

 

Salary starting

Salary ending

  Telephone          
Your Title   Name and title of supervisor  
May we
  contact?      
Describe yor duties   Reason for leaving              

Name of employer Street Address City State Zip  

Dates employed

from to

 

Salary starting

Salary ending

  Telephone          
Your Title   Name and title of supervisor  
May we
  contact?      
Describe yor duties   Reason for leaving              

Name of employer Street Address City State Zip  

Dates employed

from to

 

Salary starting

Salary ending

  Telephone          
Your Title   Name and title of supervisor  
May we
  contact?      
Describe yor duties   Reason for leaving              

Name of employer Street Address City State Zip  

Dates employed

from to

 

Salary starting

Salary ending

  Telephone          
Your Title   Name and title of supervisor  
May we
  contact?      
Describe yor duties   Reason for leaving              

REFERENCES
List name and telephone number of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.
Name: Telephone:
Years known:
 
Name:   Telephone:  
Years known:
 
Name:   Telephone:  
Years known:
 

MEMBERSHIP
List professional, trade, business, or civic associations and any offices held. (Exclude any memberships, which would reveal sex, race, religion, national origin, age, color, disability or other protected status)
Organization Offices held  
Organization Offices held  
Organization Offices held  

HONORS
List special accomplishments, publications, and awards. (Exclude honors, which would reveal sex, race, religion, national origin, age, color, disability or other protected status)

OTHER INFORMATION
List any additional information you would like us to consider:

EMPLOYMENT-RELATED INFORMATION
Have you ever been employed by Disciples Benevolent Services?   If yes, give position(s).  

Are you prevented from lawfully becoming employed in this country because of visa or immigration status?

     
Proof of citizenship or immigration status will be required upon employment.      

STATEMENT OF NONDISCRIMINATION

It is the policy of the Disciples Benevolent Services to select and promote employees solely on the basis of merit and qualifications as related to the requirements of the job to be filled, without regard to race, color, religion, sex, national origin, handicap or status as a veteran

APPLICANT'S CERTIFICATION AND AGREEMENT

          I certify that all information given is true, correct, and complete, and that I have not withheld any information, which would, if disclosed, affect my Application unfavorably.  I understand that false or misleading statements or omissions on this Application could result in disqualification from further consideration for employment and, if discovered after employment, could result in immediate dismissal. I hereby authorize the Disciples Benevolent Services and/or its agents to make an investigation of my background, including (but not limited to) an investigation of my references, character, general reputation, personal characteristics, mode of living, current and past employment, education, and criminal history, which may be conducted through personal interviews with anyone anywhere at any time, in person, via telephone, or otherwise (including with my current and past employers, except as permission is otherwise denied herein), and/or which may be obtained from any federal, state, or local files, including those maintained by both public and private organizations, for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for employment, including my moral character.  A telephone facsimile (fax) or xerographic copy of the consent shall be considered as valid as the original.
          I release the Disciples Benevolent Services and/or its agents and any person or entity which provides information pursuant to this authorization from any and all liabilities, claims, or lawsuits arising out of or relating to the information obtained from any and all of the above-referenced sources.
          I understand that employment at the Disciples Benevolent Services is "at will", which means that if employed, either I or the Disciples Benevolent Services can terminate or modify my employment at any time, with or without notice, and with or without cause.  If employed, my employment will be for no definite period of time.  I understand that no supervisor, manager, or executive of the Disciples Benevolent Services has any authority to alter the foregoing.
  Note: You will be asked to sign this agreement upon meeting us at an interview

ENCLOSURE TO APPLICATION
NOTICE OF BACKGROUND SEARCH AND INVESTIGATION

          You are advised that in connection with your application for employment, the Disciples Benevolent Services may make an investigation of your background, references, character, past employment, consumer reports, education, and criminal history record information, which may be conducted through personal interviews, or which may be obtained from any state or local files, including those maintained by both public and private organizations, and all public records, for the purpose of confirming the information contained in your application and/or obtaining other information which may be material to your qualifications for employment.

 
          You are further advised that you have a right under the Fair Credit Reporting Act (the “Act”) to make a written request within a reasonable period of time for additional information regarding the nature and scope of this investigation, as well as for a written summary of your rights under the Act.  You are further advised that prior to taking any adverse action based in whole or in part on this investigation, the Disciples Benevolent Services will provide you a copy of any consumer report obtained therein and a summary of your rights under the Act.

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